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Kruth SS, Willers C, Persad E, Sjöström ES, Lagerström SR, Rakow A. Probiotic supplementation and risk of necrotizing enterocolitis and mortality among extremely preterm infants-the Probiotics in Extreme Prematurity in Scandinavia (PEPS) trial: study protocol for a multicenter, double-blinded, placebo-controlled, and registry-based randomized controlled trial. Trials 2024; 25:259. [PMID: 38610034 PMCID: PMC11015611 DOI: 10.1186/s13063-024-08088-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 04/02/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Extremely preterm infants, defined as those born before 28 weeks' gestational age, are a very vulnerable patient group at high risk for adverse outcomes, such as necrotizing enterocolitis and death. Necrotizing enterocolitis is an inflammatory gastrointestinal disease with high incidence in this cohort and has severe implications on morbidity and mortality. Previous randomized controlled trials have shown reduced incidence of necrotizing enterocolitis among older preterm infants following probiotic supplementation. However, these trials were underpowered for extremely preterm infants, rendering evidence for probiotic supplementation in this population insufficient to date. METHODS The Probiotics in Extreme Prematurity in Scandinavia (PEPS) trial is a multicenter, double-blinded, placebo-controlled and registry-based randomized controlled trial conducted among extremely preterm infants (n = 1620) born at six tertiary neonatal units in Sweden and four units in Denmark. Enrolled infants will be allocated to receive either probiotic supplementation with ProPrems® (Bifidobacterium infantis, Bifidobacterium lactis, and Streptococcus thermophilus) diluted in 3 mL breastmilk or placebo (0.5 g maltodextrin powder) diluted in 3 mL breastmilk per day until gestational week 34. The primary composite outcome is incidence of necrotizing enterocolitis and/or mortality. Secondary outcomes include incidence of late-onset sepsis, length of hospitalization, use of antibiotics, feeding tolerance, growth, and body composition at age of full-term and 3 months corrected age after hospital discharge. DISCUSSION Current recommendations for probiotic supplementation in Sweden and Denmark do not include extremely preterm infants due to lack of evidence in this population. However, this young subgroup is notably the most at risk for experiencing adverse outcomes. This trial aims to investigate the effects of probiotic supplementation on necrotizing enterocolitis, death, and other relevant outcomes to provide sufficiently powered, high-quality evidence to inform probiotic supplementation guidelines in this population. The results could have implications for clinical practice both in Sweden and Denmark and worldwide. TRIAL REGISTRATION ( Clinicaltrials.gov ): NCT05604846.
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Affiliation(s)
- Sofia Söderquist Kruth
- Women's Health and Allied Health Professional Theme, Karolinska University Hospital, Solna, 17176, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, 17177, Stockholm, Sweden
| | - Carl Willers
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, 14152, Huddinge, Sweden
| | - Emma Persad
- Department of Women's and Children's Health, Karolinska Institutet, 17177, Stockholm, Sweden
| | | | - Susanne Rautiainen Lagerström
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- K2 Medicin, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Alexander Rakow
- Department of Women's and Children's Health, Karolinska Institutet, 17177, Stockholm, Sweden.
- Department of Neonatology, Karolinska University Hospital, Solna, 17176, Stockholm, Sweden.
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Diller N, Osborn DA, Birch P. Higher versus lower sodium intake for preterm infants. Cochrane Database Syst Rev 2023; 10:CD012642. [PMID: 37824273 PMCID: PMC10569379 DOI: 10.1002/14651858.cd012642.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
BACKGROUND Infants born preterm are at increased risk of early hypernatraemia (above-normal blood sodium levels) and late hyponatraemia (below-normal blood sodium levels). There are concerns that imbalances of sodium intake may impact neonatal morbidities, growth and developmental outcomes. OBJECTIVES To determine the effects of higher versus lower sodium supplementation in preterm infants. SEARCH METHODS We searched CENTRAL in February 2023; and MEDLINE, Embase and trials registries in March and April 2022. We checked reference lists of included studies and systematic reviews where subject matter related to the intervention or population examined in this review. We compared early (< 7 days following birth), late (≥ 7 days following birth), and early and late sodium supplementation, separately. SELECTION CRITERIA We included randomised, quasi-randomised or cluster-randomised controlled trials that compared nutritional supplementation that included higher versus lower sodium supplementation in parenteral or enteral intake, or both. Eligible participants were preterm infants born before 37 weeks' gestational age or with a birth weight less than 2500 grams, or both. We excluded studies that had prespecified differential water intakes between groups. DATA COLLECTION AND ANALYSIS Two review authors independently assessed eligibility and risk of bias, and extracted data. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS We included nine studies in total. However, we were unable to extract data from one study (20 infants); some studies contributed to more than one comparison. Eight studies (241 infants) were available for quantitative meta-analysis. Four studies (103 infants) compared early higher versus lower sodium intake, and four studies (138 infants) compared late higher versus lower sodium intake. Two studies (103 infants) compared intermediate sodium supplementation (≥ 3 mmol/kg/day to < 5 mmol/kg/day) versus no supplementation, and two studies (52 infants) compared higher sodium supplementation (≥ 5 mmol/kg/day) versus no supplementation. We assessed only two studies (63 infants) as low risk of bias. Early (less than seven days following birth) higher versus lower sodium intake Early higher versus lower sodium intake may not affect mortality (risk ratio (RR) 1.02, 95% confidence interval (CI) 0.38 to 2.72; I2 = 0%; 3 studies, 83 infants; low-certainty evidence). Neurodevelopmental follow-up was not reported. Early higher versus lower sodium intake may lead to a similar incidence of hyponatraemia < 130 mmol/L (RR 0.68, 95% CI 0.40 to 1.13; I2 = 0%; 3 studies, 83 infants; low-certainty evidence) but an increased incidence of hypernatraemia ≥ 150 mmol/L (RR 1.62, 95% CI 1.00 to 2.65; I2 = 0%; 4 studies, 103 infants; risk difference (RD) 0.17, 95% CI 0.01 to 0.34; number needed to treat for an additional harmful outcome 6, 95% CI 3 to 100; low-certainty evidence). Postnatal growth failure was not reported. The evidence is uncertain for an effect on necrotising enterocolitis (RR 4.60, 95% CI 0.23 to 90.84; 1 study, 46 infants; very low-certainty evidence). Chronic lung disease at 36 weeks was not reported. Late (seven days or more following birth) higher versus lower sodium intake Late higher versus lower sodium intake may not affect mortality (RR 0.13, 95% CI 0.01 to 2.20; 1 study, 49 infants; very low-certainty evidence). Neurodevelopmental follow-up was not reported. Late higher versus lower sodium intake may reduce the incidence of hyponatraemia < 130 mmol/L (RR 0.13, 95% CI 0.03 to 0.50; I2 = 0%; 2 studies, 69 infants; RD -0.42, 95% CI -0.59 to -0.24; number needed to treat for an additional beneficial outcome 2, 95% CI 2 to 4; low-certainty evidence). The evidence is uncertain for an effect on hypernatraemia ≥ 150 mmol/L (RR 7.88, 95% CI 0.43 to 144.81; I2 = 0%; 2 studies, 69 infants; very low-certainty evidence). A single small study reported that later higher versus lower sodium intake may reduce the incidence of postnatal growth failure (RR 0.25, 95% CI 0.09 to 0.69; 1 study; 29 infants; low-certainty evidence). The evidence is uncertain for an effect on necrotising enterocolitis (RR 0.07, 95% CI 0.00 to 1.25; 1 study, 49 infants; very low-certainty evidence) and chronic lung disease (RR 2.03, 95% CI 0.80 to 5.20; 1 study, 49 infants; very low-certainty evidence). Early and late (day 1 to 28 after birth) higher versus lower sodium intake for preterm infants Early and late higher versus lower sodium intake may not have an effect on hypernatraemia ≥ 150 mmol/L (RR 2.50, 95% CI 0.63 to 10.00; 1 study, 20 infants; very low-certainty evidence). No other outcomes were reported. AUTHORS' CONCLUSIONS Early (< 7 days following birth) higher sodium supplementation may result in an increased incidence of hypernatraemia and may result in a similar incidence of hyponatraemia compared to lower supplementation. We are uncertain if there are any effects on mortality or neonatal morbidity. Growth and longer-term development outcomes were largely unreported in trials of early sodium supplementation. Late (≥ 7 days following birth) higher sodium supplementation may reduce the incidence of hyponatraemia. We are uncertain if late higher intake affects the incidence of hypernatraemia compared to lower supplementation. Late higher sodium intake may reduce postnatal growth failure. We are uncertain if late higher sodium intake affects mortality, other neonatal morbidities or longer-term development. We are uncertain if early and late higher versus lower sodium supplementation affects outcomes.
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Affiliation(s)
- Natasha Diller
- Newborn Care, Royal Prince Alfred Hospital, Sydney, Australia
| | - David A Osborn
- Central Clinical School, School of Medicine, The University of Sydney, Sydney, Australia
| | - Pita Birch
- Department of Neonatology, Mater Mother's Hospitals South Brisbane, Brisbane, Australia
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Magnusson A, Swolin-Eide D, Elfvin A. Body composition and bone mass among 5-year-old survivors of necrotizing enterocolitis. Pediatr Res 2023; 93:924-931. [PMID: 35974161 PMCID: PMC10033411 DOI: 10.1038/s41390-022-02236-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 07/09/2022] [Accepted: 07/19/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) affects the intestine of preterm infants. Preterm infants risk inadequate bone mineralization. This risk may increase if the intestinal uptake of minerals is affected after NEC. METHODS This is a study of growth, bone mineral density (BMD), bone mineral content (BMC), and body composition at 5 years of age among Swedish children born before gestational week 37 + 0 with a history of NEC, minimum stage IIA, compared to matched controls. Fifty children, 25 NEC cases and 25 controls, were examined with dual energy X-ray absorptiometry (DXA) and DXA with laser. RESULTS The NEC cases had lower weight, -1.3 SDS vs -0.7 SDS, a lower fat mass and fat percent, 23.4 vs 29.1%, compared to the controls. NEC cases had lower BMC total body head excluded, 355.6 g vs 416.7 g. BMD Z-scores were lower among NEC cases in total body head excluded, -0.7 vs -0.1, and in lumbar spine. CONCLUSIONS Preterm NEC survivors at 5 years of age had reduced growth, an altered body composition, and indications of a lower bone mass compared to matched controls. The study suggests that preterm infants diagnosed with NEC need special attention during childhood regarding growth and bone health. IMPACT A follow-up longitudinal study of growth, bone health, and body composition at 5 years of age among children born preterm with a history of NEC compared to matched controls. The NEC cases had lower weight than controls. NEC cases had an altered body composition with lower fat mass compared to controls. The DXA results showed that the NEC cases had lower bone mineral content and a tendency to lower bone mineral density. The study suggests that preterm infants diagnosed with NEC need special attention at follow-up regarding growth and bone health compared to preterm infants without NEC.
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Affiliation(s)
- Amanda Magnusson
- Department of Pediatrics, Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Pediatrics, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Diana Swolin-Eide
- Department of Pediatrics, Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Pediatrics, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Elfvin
- Department of Pediatrics, Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Region Västra Götaland, Department of Pediatrics, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Späth C, Stoltz Sjöström E, Ågren J, Ahlsson F, Domellöf M. Sodium supply from administered blood products was associated with severe intraventricular haemorrhage in extremely preterm infants. Acta Paediatr 2022; 111:1701-1708. [PMID: 35615868 PMCID: PMC9543447 DOI: 10.1111/apa.16423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 05/03/2022] [Accepted: 05/24/2022] [Indexed: 11/29/2022]
Abstract
Aim The aim of this study was to investigate the associations between sodium supply, fluid volume, sodium imbalances and severe intraventricular haemorrhage (IVH) in extremely preterm (EPT) infants. Methods We used data from the EXtremely PREterm infants in Sweden Study (EXPRESS) cohort consisting of all infants born at 22 to 26 gestational weeks from 2004 to 2007 and conducted a nested case–control study. For every infant with severe IVH (grade 3 or peri‐ventricular haemorrhagic infarction), one IVH‐free control infant with the birthday closest to the case infant and matched for hospital, sex, gestational age and birth weight was selected (n = 70 case–control pairs). Results Total sodium supply and fluid volume were higher in infants with severe IVH compared with controls [daily total sodium supply until postnatal Day 2: mean ± SD (mmol/kg/day): 5.49 ± 2.53 vs. 3.95 ± 1.91, p = 0.009]. These differences were accounted for by sodium and fluid from transfused blood products. High plasma sodium concentrations or large sodium fluctuations were not associated with severe IVH. Conclusion Our results suggest a relationship between sodium‐rich transfusions of blood products and severe IVH in EPT infants. It is unclear whether this is an effect of sodium load, volume load or some other transfusion‐related factor.
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Affiliation(s)
- Cornelia Späth
- Department of Clinical Sciences, Pediatrics Umeå University Umeå Sweden
| | | | - Johan Ågren
- Department of Women's and Children's Health Uppsala University Uppsala Sweden
| | - Fredrik Ahlsson
- Department of Women's and Children's Health Uppsala University Uppsala Sweden
| | - Magnus Domellöf
- Department of Clinical Sciences, Pediatrics Umeå University Umeå Sweden
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Sato J, Vandewouw MM, Safar K, Ng DVY, Bando N, O’Connor DL, Unger SL, Pang E, Taylor MJ. Social-Cognitive Network Connectivity in Preterm Children and Relations With Early Nutrition and Developmental Outcomes. Front Syst Neurosci 2022; 16:812111. [PMID: 35465192 PMCID: PMC9022474 DOI: 10.3389/fnsys.2022.812111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/18/2022] [Indexed: 11/13/2022] Open
Abstract
Infants born very low birth weight (VLBW, < 1,500 g) are at a heightened risk for structural brain abnormalities and social-cognitive deficits, which can impair behavioural functioning. Resting-state fMRI, reflecting a baseline level of brain activity and underlying social-cognitive processes, has also been reported to be altered in children born VLBW. Yet very little is known about the functional networks underlying social cognition using magnetoencephalography (MEG) and how it relates to neonatal factors and developmental outcomes. Thus, we investigated functional connectivity at rest in VLBW children and the associations with early nutrition and IQ and behavioural problems. We collected resting-state MEG recordings and measures of IQ and social-cognitive behaviour, as well as macronutrient/energy intakes during initial hospitalisation in 5-year-old children born VLBW (n = 37) compared to full-term (FT; n = 27) controls. We examined resting-state network differences controlling for sex and age at scan. Functional connectivity was estimated using the weighted phase lag index. Associations between functional connectivity with outcome measures and postnatal nutrition were also assessed using regression analyses. We found increased resting-state functional connectivity in VLBW compared to FT children in the gamma frequency band (65–80 Hz). This hyper-connected network was primarily anchored in frontal regions known to underlie social-cognitive functions such as emotional processing. In VLBW children, increased functional connectivity was related to higher IQ scores, while reduced connectivity was related to increased behavioural problems at 5 years of age. These within-group associations were found in the slower frequency bands of theta (4–7 Hz) and alpha (8–12 Hz), frequently linked to higher-order cognitive functions. We also found significant associations between macronutrient (protein and lipid) and energy intakes during the first postnatal month with functional connectivity at preschool-age, highlighting the long-term impacts of postnatal nutrition on preterm brain development. Our findings demonstrate that at preschool-age, VLBW children show altered resting-state connectivity despite IQ and behaviour being in the average range, possibly reflecting functional reorganisation of networks to support social-cognitive and behavioural functioning. Further, our results highlight an important role of early postnatal nutrition in the development of resting-state networks, which in turn may improve neurodevelopmental outcomes in this vulnerable population.
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Affiliation(s)
- Julie Sato
- Diagnostic Imaging, Hospital for Sick Children, Toronto, ON, Canada
- Department of Psychology, University of Toronto, Toronto, ON, Canada
- Division of Neurosciences and Mental Health, Hospital for Sick Children, Toronto, ON, Canada
- *Correspondence: Julie Sato,
| | - Marlee M. Vandewouw
- Diagnostic Imaging, Hospital for Sick Children, Toronto, ON, Canada
- Division of Neurosciences and Mental Health, Hospital for Sick Children, Toronto, ON, Canada
- Autism Research Centre, Holland Bloorview Kids Rehabilitation Hospital, Bloorview Research Institute, Toronto, ON, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
| | - Kristina Safar
- Diagnostic Imaging, Hospital for Sick Children, Toronto, ON, Canada
- Division of Neurosciences and Mental Health, Hospital for Sick Children, Toronto, ON, Canada
| | - Dawn V. Y. Ng
- Division of Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Nutritional Sciences, University of Toronto, Toronto, ON, Canada
| | - Nicole Bando
- Division of Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Deborah L. O’Connor
- Division of Translational Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Nutritional Sciences, University of Toronto, Toronto, ON, Canada
- Department of Paediatrics, Sinai Health, Toronto, ON, Canada
| | - Sharon L. Unger
- Department of Nutritional Sciences, University of Toronto, Toronto, ON, Canada
- Department of Paediatrics, Sinai Health, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Division of Neonatology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Elizabeth Pang
- Division of Neurosciences and Mental Health, Hospital for Sick Children, Toronto, ON, Canada
- Division of Neurology, Hospital for Sick Children, Toronto, ON, Canada
| | - Margot J. Taylor
- Diagnostic Imaging, Hospital for Sick Children, Toronto, ON, Canada
- Department of Psychology, University of Toronto, Toronto, ON, Canada
- Division of Neurosciences and Mental Health, Hospital for Sick Children, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
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Gialamas S, Stoltz Sjöström E, Diderholm B, Domellöf M, Ahlsson F. Amino acid infusions in umbilical artery catheters enhance protein administration in infants born at extremely low gestational age. Acta Paediatr 2022; 111:536-545. [PMID: 34822182 DOI: 10.1111/apa.16196] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/22/2021] [Accepted: 11/24/2021] [Indexed: 11/30/2022]
Abstract
AIM It is challenging to provide extremely low gestational age neonates (ELGANs) with adequate protein supply. This study aimed to investigate whether amino acid (AA) infusion in the umbilical artery catheter (UAC) in ELGANs is safe and enhances protein supply and growth. METHOD A before and after study including infants born <27 weeks, treated in Uppsala, Sweden, during 2004-2007, compared those receiving normal saline/10% dextrose in water with those receiving AA infusion in the UAC. Data were retrieved from the Extremely Preterm Infants in Sweden Study, hospital records and the Swedish Neonatal Quality Register. Group comparisons, univariate and multivariate analyses were conducted. RESULTS AA group (n = 41, females 39%) received on average approximately 0.3 g/kg/day more protein during the first postnatal week, compared to control group (n = 30, females 40%) (unstandardised coefficient (B) 0.26, p .001) but no difference was noted during 8-28 postnatal days. The type of infusion was not associated with growth variables. The incidence of neonatal morbidities and UAC-related thrombosis did not differ between the groups. CONCLUSION AA infusions in the UACs in ELGANs is safe and enhances protein supply during the first postnatal week. However, this practice is not associated with growth during the first 28 postnatal days.
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Affiliation(s)
- Spyros Gialamas
- Department of Women’s and Children’s Health Uppsala University Uppsala Sweden
| | | | - Barbro Diderholm
- Department of Women’s and Children’s Health Uppsala University Uppsala Sweden
| | - Magnus Domellöf
- Department of Clinical Sciences, Pediatrics Umeå University Umeå Sweden
| | - Fredrik Ahlsson
- Department of Women’s and Children’s Health Uppsala University Uppsala Sweden
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Do Maternal Factors and Milk Expression Patterns Affect the Composition of Donor Human Milk? Nutrients 2021; 13:nu13072425. [PMID: 34371935 PMCID: PMC8308884 DOI: 10.3390/nu13072425] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/08/2021] [Accepted: 07/13/2021] [Indexed: 11/23/2022] Open
Abstract
A primary role of Human Milk Banks (HMBs) is to provide human milk (HM) for preterm infants and to support the mothers of these infants as they establish their own milk supply. A better understanding of the variation in the energy and macronutrients contents of donor human milk (DHM) potentiates targeted nutrition for preterm babies. Therefore, the aim of this study was to assess the variability of energy and macronutrients content in DHM and to investigate the impact of maternal factors and feeding practices on the nutritional value of DHM. The study involved 49 donors registered in the HMB in the Holy Family Hospital in Warsaw, Poland. Samples from each donor were pooled within a maximum of two weeks. The composition of DHM, including energy content, protein, fat, and carbohydrate concentrations, was analyzed using the Miris Human Milk Analyzer. The analyses were performed before the pasteurization process. The mean time of milk donation to HMB was 13.2 ± 6.0 weeks. There were no significant differences in energy and macronutrients contents of DHM in the beginning and at the end of milk donation to HMB, however, HM fat concentration was positively correlated with afternoon feedings (r = 0.289, p = 0.044). The method of feeding (breastfeeding vs. feeding only expressed milk) also did not impact the nutritional value of DHM. Future research for the DHM should include a further cross-sectional observational study with the collection of detailed donor information and characteristics of milk expression and feeding practices to further evaluate the pooling processes and the effect on DHM composition.
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Wang N, Cui L, Liu Z, Wang Y, Zhang Y, Shi C, Cheng Y. Optimizing parenteral nutrition to achieve an adequate weight gain according to the current guidelines in preterm infants with birth weight less than 1500 g: a prospective observational study. BMC Pediatr 2021; 21:303. [PMID: 34233641 PMCID: PMC8260575 DOI: 10.1186/s12887-021-02782-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 06/10/2021] [Indexed: 11/12/2022] Open
Abstract
Aim European Society for Clinical Nutrition and Metabolism released the guidelines on pediatric parenteral nutrition in 2018. We aimed to compare the parenteral nutrition (PN) regimen with the current guidelines, evaluate weight gain and explore the correlation of parenteral macronutrient and energy intakes with weight gain outcome in preterm infants with birth weight less than 1500 g. Methods A prospective observational study was conducted. Parenteral macronutrients and energy intakes were described. Weight gain during PN was assessed. Nutritional factors associated with weight gain outcome after PN were identified using a cox proportional hazards model. Results A total of 163 infants were included in this study, in which 41 were extremely low birth weight (ELBW) infants and 122 were very low birth weight (VLBW) infants. Average glucose, amino acid, lipid, and energy during the first postnatal week were 7.5 g/kg/d, 2.4 g/kg/d, 0.8 g/kg/d, 48 kcal/kg/d. Median maximum glucose, amino acid, lipid, and energy were 11.1 g/kg/d, 3.5 g/kg/d, 3 g/kg/d, 78 kcal/kg/d. Median days to maximum glucose, amino acid, lipid, and energy were 10, 9, 12, 11 days. The proportion of appropriate for gestational age (AGA) infants was 76.9%. The ratio of infants without poor weight gain outcome after PN was 38%. With every 0.1 g/kg/d decrease of maximum amino acid and average lipid during the first postnatal week, the probability of appropriate weight gain outcome decreased by 77.6 and 74.4% respectively. With each additional day to maximum glucose and energy, the probability of appropriate weight gain outcome decreased by 5.6 and 6.1% respectively. Conclusions Most preterm infants with birth weight less than 1500 g remain below the latest recommended nutrition goals. The poor weight gain outcome of these infants after PN is related to insufficient parenteral macronutrient and energy intakes. PN strategies should be improved according to the latest evidence-based recommendations. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-021-02782-1.
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Affiliation(s)
- Nan Wang
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, 7 Wei Wu Road, Zhengzhou, 450003, Henan, China
| | - Lianlian Cui
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, 7 Wei Wu Road, Zhengzhou, 450003, Henan, China
| | - Zhen Liu
- Department of Neonatology, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, 450003, Henan, China
| | - Yan Wang
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, 7 Wei Wu Road, Zhengzhou, 450003, Henan, China
| | - Yuhua Zhang
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, 7 Wei Wu Road, Zhengzhou, 450003, Henan, China
| | - Changsong Shi
- Department of Pediatric Intensive Care Unit, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, 450003, Henan, China
| | - Yanbo Cheng
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, 7 Wei Wu Road, Zhengzhou, 450003, Henan, China.
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Hamayun J, Mohlkert LA, Stoltz Sjöström E, Domellöf M, Norman M, Zamir I. Association between Neonatal Intakes and Hyperglycemia, and Left Heart and Aortic Dimensions at 6.5 Years of Age in Children Born Extremely Preterm. J Clin Med 2021; 10:2554. [PMID: 34207785 PMCID: PMC8230069 DOI: 10.3390/jcm10122554] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/27/2021] [Accepted: 06/03/2021] [Indexed: 12/29/2022] Open
Abstract
Survivors of extremely preterm birth (gestational age < 27 weeks) have been reported to exhibit an altered cardiovascular phenotype in childhood. The mechanisms are unknown. We investigated associations between postnatal nutritional intakes and hyperglycemia, and left heart and aortic dimensions in children born extremely preterm. Postnatal nutritional data and echocardiographic dimensions at 6.5 years of age were extracted from a sub-cohort of the Extremely Preterm Infants in Sweden Study (EXPRESS; children born extremely preterm between 2004-2007, n = 171, mean (SD) birth weight = 784 (165) grams). Associations between macronutrient intakes or number of days with hyperglycemia (blood glucose > 8 mmol/L) in the neonatal period (exposure) and left heart and aortic dimensions at follow-up (outcome) were investigated. Neonatal protein intake was not associated with the outcomes, whereas higher lipid intake was significantly associated with larger aortic root diameter (B = 0.040, p = 0.009). Higher neonatal carbohydrate intake was associated with smaller aorta annulus diameter (B = -0.016, p = 0.008). Longer exposure to neonatal hyperglycemia was associated with increased thickness of the left ventricular posterior wall (B = 0.004, p = 0.008) and interventricular septum (B = 0.004, p = 0.010). The findings in this study indicate that postnatal nutrition and hyperglycemia may play a role in some but not all long-lasting developmental adaptations of the cardiovascular system in children born extremely preterm.
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Affiliation(s)
- Jawwad Hamayun
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, 141 52 Stockholm, Sweden; (L.-A.M.); (M.N.)
| | - Lilly-Ann Mohlkert
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, 141 52 Stockholm, Sweden; (L.-A.M.); (M.N.)
- Department of Pediatric Cardiology, Sachs’ Children and Youth Hospital, Södersjukhuset, 118 83 Stockholm, Sweden
| | | | - Magnus Domellöf
- Department of Clinical Sciences, Pediatrics, Umeå University, 901 87 Umeå, Sweden; (M.D.); (I.Z.)
| | - Mikael Norman
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, 141 52 Stockholm, Sweden; (L.-A.M.); (M.N.)
- Department of Neonatal Medicine, Karolinska University Hospital, 141 86 Stockholm, Sweden
| | - Itay Zamir
- Department of Clinical Sciences, Pediatrics, Umeå University, 901 87 Umeå, Sweden; (M.D.); (I.Z.)
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10
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Shama S, Unger S, Pouliot Y, Doyen A, Suwal S, Pencharz P, Pitino MA, Sergius M, Aufreiter S, Stone D, O'Connor DL. A Human Milk-Based Protein Concentrate Developed for Preterm Infants Retains Bioactive Proteins and Supports Growth of Weanling Rats. J Nutr 2021; 151:840-847. [PMID: 33693847 PMCID: PMC8030702 DOI: 10.1093/jn/nxaa383] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/12/2020] [Accepted: 11/10/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Bovine milk-based protein modulars are currently available to nutrient-enrich enteral feedings; however, they have limitations for use in very-low-birth-weight infants. OBJECTIVES Our objectives were to develop a human milk-based protein (HMP) concentrate and to conduct a preclinical assessment of the HMP concentrate in weanling rats. METHODS An HMP concentrate was produced from donor milk using pressure-driven membrane filtration processes and high hydrostatic pressure processing. Protein and lactoferrin concentrations and lysozyme activity were determined by Kjeldahl, HPLC, and turbidimetric assay, respectively. Male Sprague Dawley rats 24 d old (n = 30) were randomly assigned to 1 of 3 isocaloric AIN-93G diets for 4 wk containing 100% casein (control) or with 50% of the casein replaced with the HMP concentrate (treatment) or a bovine whey protein isolate (treatment). Body weight, food intake, fat mass, plasma amino acid profiles, and organ weights were measured. Data were analyzed using linear regression models. RESULTS Raw donor milk contained (mean ± SD) 101 ± 6 g protein/kg and 5 ± 1 g lactoferrin/kg of milk solids. Postprocessing, protein and lactoferrin concentrations were 589 ± 3 g/kg and 29 ± 10 g/kg, respectively. Lysozyme activity was initially 209 ± 4 U/kg and increased to 959 ± 39 U/kg in the HMP concentrate. There were no statistically significant differences in body weight, food intake, fat mass, or plasma amino acid profiles between rats fed diets containing the HMP concentrate and the control diet. Full cecum weights were higher in rats fed the HMP concentrate than in those fed control diets (mean difference: 5.59 g; 95% CI: 4.50, 6.68 g; P < 0.0001), likely reflecting the concentration of human milk oligosaccharides. No differences were found for other organ weights. CONCLUSIONS The HMP concentrate retained important bioactive proteins and supported normal rat growth in the preclinical assessment.
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Affiliation(s)
- Sara Shama
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sharon Unger
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Department of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
- Rogers Hixon Ontario Human Milk Bank, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Yves Pouliot
- Department of Food Sciences, Institute of Nutrition and Functional Foods (INAF), Dairy Science and Technology Research Centre (STELA), Laval University, Quebec City, Quebec, Canada
| | - Alain Doyen
- Department of Food Sciences, Institute of Nutrition and Functional Foods (INAF), Dairy Science and Technology Research Centre (STELA), Laval University, Quebec City, Quebec, Canada
| | - Shyam Suwal
- Department of Food Sciences, Institute of Nutrition and Functional Foods (INAF), Dairy Science and Technology Research Centre (STELA), Laval University, Quebec City, Quebec, Canada
| | - Paul Pencharz
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Michael A Pitino
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mélanie Sergius
- Department of Food Sciences, Institute of Nutrition and Functional Foods (INAF), Dairy Science and Technology Research Centre (STELA), Laval University, Quebec City, Quebec, Canada
| | - Susanne Aufreiter
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Debbie Stone
- Rogers Hixon Ontario Human Milk Bank, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Deborah L O'Connor
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
- Rogers Hixon Ontario Human Milk Bank, Mount Sinai Hospital, Toronto, Ontario, Canada
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11
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Sato J, Vandewouw MM, Bando N, Ng DVY, Branson HM, O'Connor DL, Unger SL, Taylor MJ. Early nutrition and white matter microstructure in children born very low birth weight. Brain Commun 2021; 3:fcab066. [PMID: 33977266 PMCID: PMC8100003 DOI: 10.1093/braincomms/fcab066] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 02/17/2021] [Accepted: 02/23/2021] [Indexed: 12/31/2022] Open
Abstract
Infants born at very low birth weight (<1500 g) are vulnerable to nutritional deficits during their first postnatal month, which are associated with poor neurodevelopmental outcomes. Despite this knowledge, the impact of early postnatal nutrition on white matter microstructure in children born with very low birth weight has not been investigated. In this prospective cohort study, we employed a whole-brain approach to investigate associations between precise estimates of nutrient intake within the first postnatal month with white matter microstructure at 5 years of age. Detailed information about breastmilk, macronutrient and energy intakes during this period were prospectively recorded for all participants. Multi-shell diffusion and T1-weighted MRIs were acquired in 41 children (21 males; mean scan age: 5.75 ± 0.22 years; mean birth weight: 1028.6 ± 256.8 g). The diffusion tensor imaging and neurite orientation dispersion and density imaging models were used to obtain maps of fractional anisotropy, radial diffusivity, orientation dispersion and neurite density indices. Tract-based spatial statistics was used to test associations between metrics of white matter microstructure with breastmilk, macronutrient (protein, lipids and carbohydrate) and energy intake. Associations between white matter microstructure and cognitive outcomes were also examined. Compared to children who did not meet enteral feeding recommendations, those who achieved enteral protein, lipid and energy recommendations during the first postnatal month showed improved white matter maturation at 5 years. Among the macronutrients, greater protein intake contributed most to the beneficial effect of nutrition, showing widespread increases in fractional anisotropy and reductions in radial diffusivity. No significant associations were found between white matter metrics with breastmilk or carbohydrate intake. Voxel-wise analyses with cognitive outcomes revealed significant associations between higher fractional anisotropy and neurite density index with higher processing speed scores. Lower radial diffusivity and orientation dispersion index were also associated with improved processing speed. Our findings support the long-term impacts of early nutrition on white matter microstructure, which in turn is related to cognitive outcomes. These results provide strong support for early postnatal nutritional intervention as a promising strategy to improve long-term cognitive outcomes of infants born at very low birth weight.
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Affiliation(s)
- Julie Sato
- Diagnostic Imaging, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada.,Psychology, University of Toronto, Toronto, ON, Canada.,Neurosciences & Mental Health, Hospital for Sick Children, Toronto, ON, Canada
| | - Marlee M Vandewouw
- Diagnostic Imaging, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada.,Neurosciences & Mental Health, Hospital for Sick Children, Toronto, ON, Canada.,Autism Research Centre, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada.,Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
| | - Nicole Bando
- Translational Medicine, SickKids Research Institute, Toronto, ON, Canada
| | - Dawn V Y Ng
- Translational Medicine, SickKids Research Institute, Toronto, ON, Canada.,Nutritional Sciences, University of Toronto, Toronto, ON, Canada
| | - Helen M Branson
- Diagnostic Imaging, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada.,Medical Imaging, University of Toronto, ON, Canada
| | - Deborah L O'Connor
- Translational Medicine, SickKids Research Institute, Toronto, ON, Canada.,Nutritional Sciences, University of Toronto, Toronto, ON, Canada
| | - Sharon L Unger
- Nutritional Sciences, University of Toronto, Toronto, ON, Canada.,Paediatrics, University of Toronto, Toronto, ON, Canada.,Paediatrics, Mount Sinai Health, Toronto, ON, Canada.,Division of Neonatology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Margot J Taylor
- Diagnostic Imaging, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada.,Psychology, University of Toronto, Toronto, ON, Canada.,Neurosciences & Mental Health, Hospital for Sick Children, Toronto, ON, Canada.,Medical Imaging, University of Toronto, ON, Canada.,Paediatrics, University of Toronto, Toronto, ON, Canada
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12
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Bishara R, Asbury MR, Ng DVY, Bando N, Ng E, Unger S, O'Connor DL. Higher Energy, Lipid, and Carbohydrate Provision to Very Low-Birth-Weight Infants Is Differentially Associated With Neurodevelopment at 18 Months, Despite Consistent Improvements in Weight Gain. JPEN J Parenter Enteral Nutr 2021; 45:1762-1773. [PMID: 33769577 DOI: 10.1002/jpen.2072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 01/06/2020] [Indexed: 11/11/2022]
Abstract
BACKGROUND The impact of suboptimal intakes on neurodevelopment of very low-birth-weight (VLBW, <1500 g) infants, particularly those born small for gestational age, <26 weeks, <1000 g, or with morbidities is not well defined. We investigated how macronutrient/energy intakes are associated with growth and neurodevelopment among VLBW infants, adjusted for the aforementioned vulnerabilities. Our hypothesis was that higher nutrient intakes would be positively associated with weight gain and neurodevelopment. METHODS Daily macronutrient/energy intakes and weekly weights from birth until 36+0 weeks were collected prospectively from VLBW infants (n = 302) enrolled in a previous trial (ISRCTN35317141). Neurodevelopment was assessed by the Bayley-III at 18 months' corrected gestational age. Relationships between quartiles of macronutrient/energy intakes, growth, and neurodevelopment were assessed. RESULTS Infants born <1000 g, <26 weeks, or with morbidities had lower nutrient intakes and slower growth than infants born ≥1000 g, ≥26 weeks, or with no morbidities, respectively (P < 0.05). Higher quartiles of energy, lipid, and carbohydrate intakes were positively associated with growth velocity (P = <0.0001-0.007); no association was observed for protein intake. Energy, protein-to-energy ratio and lipid intakes were associated with cognitive scores (P = 0.001-0.004); however, intakes within the second and third quartiles were generally associated with the highest cognitive scores. No nutrient intakes were associated with language or motor scores across the entire study period. CONCLUSION Smaller, more immature VLBW infants and those with morbidity have the greatest risk of poor nutrition and growth. Increasing macronutrient/energy intakes are generally associated with improved weight gain, but not necessarily improved neurodevelopment.
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Affiliation(s)
- Rosine Bishara
- DAN Women & Babies Program, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Michelle R Asbury
- Department of Nutritional Sciences, University of Toronto, Toronto, Canada.,Translational Medicine Program, The Hospital for Sick Children, Toronto, Canada
| | - Dawn V Y Ng
- Department of Nutritional Sciences, University of Toronto, Toronto, Canada.,Translational Medicine Program, The Hospital for Sick Children, Toronto, Canada
| | - Nicole Bando
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Canada
| | - Eugene Ng
- DAN Women & Babies Program, Sunnybrook Health Sciences Centre, Toronto, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Sharon Unger
- Department of Nutritional Sciences, University of Toronto, Toronto, Canada.,Translational Medicine Program, The Hospital for Sick Children, Toronto, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada.,Department of Pediatrics, Sinai Health Systems, Toronto, Canada
| | - Deborah L O'Connor
- Department of Nutritional Sciences, University of Toronto, Toronto, Canada.,Translational Medicine Program, The Hospital for Sick Children, Toronto, Canada.,Department of Pediatrics, Sinai Health Systems, Toronto, Canada
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- DAN Women & Babies Program, Sunnybrook Health Sciences Centre, Toronto, Canada
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13
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Abdul Hamid H, Szatkowski L, Budge H, Cheah FC, Ojha S. Nutritional practices and growth of preterm infants in two neonatal units in the UK and Malaysia: a prospective exploratory study. BMJ Paediatr Open 2021; 5:e001153. [PMID: 34514178 PMCID: PMC8386205 DOI: 10.1136/bmjpo-2021-001153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 08/12/2021] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE To explore differences in nutritional practices and growth outcomes among preterm infants in neonatal units in Malaysia and the UK. DESIGN Prospective exploratory study of infants born at <34 weeks gestational age (GA). SETTING Two neonatal units, one in Malaysia and one in the UK (May 2019 to March 2020). METHODS Data collected from birth until discharge and compared between units. RESULTS From 100 infants included, median GA (IQR) was 31 (30-33) and mean±SD birth weight was 1549±444 g. There were more small-for-gestational age infants in Malaysian unit: 12/50 (24%) vs UK: 3/50 (6%), p=0.012 and more morbidities. More Malaysian infants received breast milk (Malaysia: 49 (98%) vs UK: 38 (76%), p=0.001), fortified breast milk (Malaysia: 43 (86%) vs UK: 13 (26%), p<0.001) and exclusive breast milk at discharge (Malaysia: 26 (52%) vs UK: 16 (32%), p=0.043). There was higher parenteral nutrition use among Malaysian infants (40/50 (80%)) vs UK (19/50 (38%)) (p<0.001) with higher protein intake (mean±SD Malaysia: 3.0±0.5 vs UK: 2.7±0.6 g/kg/d, p=0.004) in weeks 1-4 and smaller cumulative protein deficits (mean±SD Malaysia: 11.4±6.1 vs UK: 15.4±8.0 g/kg, p=0.006). There were no significant differences in short-term growth between units and more than half of the infants in both units had ≥1.28 changes in weight-for-age Z-score at discharge (p=0.841). CONCLUSIONS An exploratory comparison of practices showed differences in patient characteristics and nutritional practices which impacted growth. Future studies with larger sample sizes and detailed analysis of maternal characteristics and infants' outcomes are needed for improving care of preterm infants in all settings.
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Affiliation(s)
- Haslina Abdul Hamid
- Population and Lifespan Sciences, School of Medicine, University of Nottingham, Nottingham, UK.,Dietetic Programme, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Lisa Szatkowski
- Population and Lifespan Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Helen Budge
- Population and Lifespan Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Fook-Choe Cheah
- Department of Paediatrics, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Shalini Ojha
- Population and Lifespan Sciences, School of Medicine, University of Nottingham, Nottingham, UK.,Neonatal Unit, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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14
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Seliga-Siwecka J, Chmielewska A, Jasińska K. Effect of targeted vs standard fortification of breast milk on growth and development of preterm infants (≤ 32 weeks): study protocol for a randomized controlled trial. Trials 2020; 21:946. [PMID: 33225961 PMCID: PMC7682103 DOI: 10.1186/s13063-020-04841-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 10/23/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Human milk is recommended for all very low birth weight infants. Breastmilk is highly variable in nutrient content, failing to meet the nutritional demands of this group. Fortification of human milk is recommended to prevent extrauterine growth retardation and associated poor neurodevelopmental outcome. However, standard fortification with fixed dose multicomponent fortifier does not account for the variability in milk composition. Targeted fortification is a promising alternative and needs further investigation. METHODS This randomized controlled trial will recruit preterm infants (≤ 32 weeks of gestation) within the first 7 days of life. After reaching 80 ml/kg/day of enteral feeding, patients will be randomized to receive standard fortification (HMF, Nutricia) or targeted fortification (modular components: Bebilon Bialka, Nutricia-protein; Polycal, Nutricia-carbohydrates; Calogen, Nutricia-lipids). The intervention will continue until 37 weeks of post-conception age or hospital discharge. Parents and outcome assessors will be blinded to the intervention. The primary outcome measure is velocity of weight, length, and head growth until 36 weeks post-conceptional age or discharge. Secondary outcomes include neurodevelopment at 12 months assessed with Bayley Scale of Development III, repeated at 36 months; body composition at discharge and at 4 months; and incidence of necrotizing enterocolitis, sepsis, retinopathy of prematurity, and bronchopulmonary dysplasia. DISCUSSION Targeted fortification has previously been shown as doable in the neonatal intensive care unit context. If it shows to improve growth and neonatal outcome, choosing the targeted fortification as a first line nutritional approach in very low birth weight infants may become a recommendation. TRIAL REGISTRATION ClinicalTrials.gov NCT03775785 , Registered on July 2019.
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Affiliation(s)
- Joanna Seliga-Siwecka
- Neonatal and Intensive Care Department, The Medical University of Warsaw, 2 Karowa Street, 00-315, Warsaw, Poland
| | | | - Katarzyna Jasińska
- Neonatal and Intensive Care Department, The Medical University of Warsaw, 2 Karowa Street, 00-315, Warsaw, Poland
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15
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A comparison of macronutrient-based methods for deriving energy values in human milk. J Perinatol 2020; 40:1688-1693. [PMID: 32665689 DOI: 10.1038/s41372-020-0731-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/21/2020] [Accepted: 07/07/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Energy values for human milk are increasingly available clinically, though there are no standards for deriving these values. We compared published calorie methods using a common set of samples. STUDY DESIGN Ten human milk samples were measured for gross and digestible macronutrients using laboratory methods. Four calorie conversion factors were used: Atwater general (ATW-GEN); Atwater milk specific (ATW-MILK), human milk specific (HUM-MILK), and combustible conversions (COMBUST). Differences in derived calories were assessed using ANOVA. RESULTS There was a significant difference (P < 0.001) in calorie values between methods. Gross macronutrients with COMBUST conversion factors produced the highest calorie values (19.4 ± 1.4 kcal/ounce) whereas digestible macronutrients with HUM-MILK conversion factors produced the lowest calorie values (16.3 ± 1.3 kcal/ounce). Mean difference between these values was 3.1 kcal/ounce (95% CI 2.5, 3.7). CONCLUSION Mean calorie difference of 3.1 kcal/ounce is clinically important for preterm infants, suggesting the need for standardization.
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16
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Alm S, Stoltz Sjöström E, Nilsson Sommar J, Domellöf M. Erythrocyte transfusions increased the risk of elevated serum ferritin in very low birthweight infants and were associated with altered longitudinal growth. Acta Paediatr 2020; 109:1354-1360. [PMID: 31782205 PMCID: PMC7317739 DOI: 10.1111/apa.15115] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 09/06/2019] [Accepted: 11/27/2019] [Indexed: 02/02/2023]
Abstract
Aim There has been a lack of population‐based longitudinal data on serum ferritin in very low birthweight (VLBW) infants during hospitalisation. Our aim was to fill this gap in the knowledge and investigate risk factors for elevated serum ferritin and associations between erythrocyte transfusions and longitudinal growth. Methods We retrospectively reviewed longitudinal data on 126 VLBW infants treated at Umeå University Hospital, Sweden, between 2010 and 2013. Results The infants' mean gestational age and birthweight were 26.9 weeks and 899 g. Most (91%) received erythrocyte transfusions, and the majority had multiple erythrocyte transfusions. There was a significant correlation between serum ferritin and the volume of transfusions. Almost two‐thirds had at least one serum ferritin measurement of more than 350 µg/L, indicating iron overload. In those with complete anthropometric data (n = 78), there was no significant effect of serum ferritin concentrations in relation to longitudinal growth, but there was a positive association between the erythrocyte transfusion dose and longitudinal growth in VLBW infants born before 25 weeks. Conclusion This is the first population‐based study to investigate longitudinal data on serum ferritin in VLBW infants during hospitalisation. The unexpected positive finding in the subgroup born at less than 25 weeks needs further research with a larger cohort.
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Affiliation(s)
- Stina Alm
- Department of Clinical Sciences Paediatrics Umeå University Umeå Sweden
| | | | | | - Magnus Domellöf
- Department of Clinical Sciences Paediatrics Umeå University Umeå Sweden
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17
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Lund A, Löfqvist C, Pivodic A, Lundgren P, Hård A, Hellström A, Hansen‐Pupp I. Unpasteurised maternal breast milk is positively associated with growth outcomes in extremely preterm infants. Acta Paediatr 2020; 109:1138-1147. [PMID: 31747093 PMCID: PMC9541184 DOI: 10.1111/apa.15102] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 09/06/2019] [Accepted: 11/18/2019] [Indexed: 12/13/2022]
Abstract
AIM Extrauterine growth restriction is common among extremely preterm infants. We explored whether intake of unpasteurised maternal milk (MM) and pasteurised donor milk (DM) was associated with longitudinal growth outcomes and neonatal morbidities in extremely preterm infants. METHODS Observational study of 90 preterm infants born between 2013 and 2015 in Gothenburg, Sweden. Data were prospectively collected on nutritional and breast milk intakes during the first 28 days. RESULTS Ninety infants (39 girls and 51 boys) with a median gestational age of 25.3 (22.7-27.9) weeks were evaluated. MM intake (mL/kg/d) correlated positively with almost all z-scores for weight, length and head circumference at 28 postnatal days and at postmenstrual age (PMA) 32 and 36 weeks. After multivariable adjustment, MM intake and weight z-score at 28 postnatal days and at PMA 32 and 36 weeks remained significantly associated. Infants consuming ≥80% MM had more favourable weight z-scores at PMA 32 and 36 weeks. Intake of DM did not correlate with any growth outcomes. Infants without retinopathy of prematurity had a significantly higher intake of MM (mL/kg/d). CONCLUSION Unpasteurised MM was positively associated with longitudinal growth outcomes. Motivating mothers to provide their infants with their own milk after preterm birth should be emphasised.
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Affiliation(s)
- Anna‐My Lund
- Department of Clinical Sciences, Paediatrics Skåne University Hospital Lund University Lund Sweden
| | - Chatarina Löfqvist
- Section for Opthalmology Department of Clinical Neuroscience Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
| | - Aldina Pivodic
- Section for Opthalmology Department of Clinical Neuroscience Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
| | - Pia Lundgren
- Section for Opthalmology Department of Clinical Neuroscience Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
| | - Anna‐Lena Hård
- Section for Opthalmology Department of Clinical Neuroscience Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
| | - Ann Hellström
- Section for Opthalmology Department of Clinical Neuroscience Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
| | - Ingrid Hansen‐Pupp
- Department of Clinical Sciences, Paediatrics Skåne University Hospital Lund University Lund Sweden
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18
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Cormack BE, Jiang Y, Harding JE, Crowther CA, Bloomfield FH. Relationships between Neonatal Nutrition and Growth to 36 Weeks' Corrected Age in ELBW Babies-Secondary Cohort Analysis from the Provide Trial. Nutrients 2020; 12:nu12030760. [PMID: 32183057 PMCID: PMC7146349 DOI: 10.3390/nu12030760] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 03/03/2020] [Accepted: 03/03/2020] [Indexed: 01/03/2023] Open
Abstract
A key modifiable factor for improving neurodevelopment in extremely low birthweight (ELBW) babies may be improving growth, especially head growth, by optimising nutrition in the early neonatal period. We aimed to investigate relationships between nutrient intakes in the 4 weeks after birth, and growth from birth to 36 weeks’ corrected age (CA) in ELBW babies. We undertook a prospective cohort study of 434 participants enrolled in a randomised controlled trial (ProVIDe) in eight New Zealand and Australian neonatal intensive care units. Macronutrient intakes from birth to 4 weeks and weight, length and head circumference measurements from birth to 36 weeks’ CA were collected. From birth to 36 weeks’ CA, the median (IQR) z-score changes were: weight −0.48 (−1.09, 0.05); length −1.16 (−1.86, −0.43), and head circumference −0.82 (−1.51, −0.19). Changes in z-score to 4 weeks and 36 weeks’ CA were correlated with protein intake. Each 1 g·Kg−1·d−1 total protein intake in week 2 was associated with 0.26 z-score increase in head circumference at 36 weeks’ CA. Both nutritional intake and change in z-scores to 36 weeks’ CA differed widely amongst sites. Correlations between nutrition and growth, and differences in these amongst sites, indicate there may be potential to improve growth with enhanced nutrition practices.
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Affiliation(s)
- Barbara E. Cormack
- Liggins Institute, University of Auckland, 1142 Auckland, New Zealand; (B.E.C.); (Y.J.); (J.E.H.); (C.A.C.)
- Newborn Services, Starship Child Health, Auckland City Hospital, 1142 Auckland, New Zealand
| | - Yannan Jiang
- Liggins Institute, University of Auckland, 1142 Auckland, New Zealand; (B.E.C.); (Y.J.); (J.E.H.); (C.A.C.)
| | - Jane E. Harding
- Liggins Institute, University of Auckland, 1142 Auckland, New Zealand; (B.E.C.); (Y.J.); (J.E.H.); (C.A.C.)
| | - Caroline A. Crowther
- Liggins Institute, University of Auckland, 1142 Auckland, New Zealand; (B.E.C.); (Y.J.); (J.E.H.); (C.A.C.)
| | - Frank H. Bloomfield
- Liggins Institute, University of Auckland, 1142 Auckland, New Zealand; (B.E.C.); (Y.J.); (J.E.H.); (C.A.C.)
- Newborn Services, Starship Child Health, Auckland City Hospital, 1142 Auckland, New Zealand
- Correspondence: ; Tel.: +64-9-923-6107
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19
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Chmielewska A, Farooqi A, Domellöf M, Ohlund I. Lean Tissue Deficit in Preterm Infants Persists up to 4 Months of Age: Results from a Swedish Longitudinal Study. Neonatology 2020; 117:80-87. [PMID: 31822002 DOI: 10.1159/000503292] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 09/10/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND At term-equivalent age, infants born prematurely are shorter, lighter and have more adipose tissue compared to term counterparts. Little is known on whether the differences in body composition persist in later age. METHODS We prospectively recruited 33 preterm infants (<32 weeks gestational age, mean gestational age 28.1 weeks) and 69 term controls. Anthropometry and body composition (air displacement plethysmography) were monitored up to 4 months of age. Nutrient intakes from preterm infants were collected from clinical records. RESULTS At 4 months of age preterm infants were lighter and shorter than term controls (mean weight-for-age z-score: -0.73 vs. 0.06, p = 0.001; mean length-for-age z-score: -1.31 vs. 0.29, p < 0.0001). The significantly greater percentage of total body fat seen in preterm infants at term-equivalent age (20.2 vs. 11.7%, p < 0.0001) was no longer observed at 4 months. A deficit of fat-free mass persisted until 4 months of age (fat-free mass at term-equivalent age: 2.71 vs. 3.18 kg, p < 0.0001; at 4 months: 4.3 vs. 4.78 kg, p < 0.0001). The fat mass index and fat-free mass index (taking length into account) did not differ between the groups. Nutrition had little effect on body composition. Higher protein intake at week 2 was a negative predictor of fat-free mass at discharge. CONCLUSIONS At 4 months corrected age, preterm infants were both lighter and shorter than term controls and the absolute fat-free mass deficit remained until this age. Little effect of nutrition on body composition was observed.
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Affiliation(s)
- Anna Chmielewska
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden,
| | - Aijaz Farooqi
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Magnus Domellöf
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Inger Ohlund
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
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20
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Asbury MR, Unger S, Kiss A, Ng DVY, Luk Y, Bando N, Bishara R, Tomlinson C, O'Connor DL. Optimizing the growth of very-low-birth-weight infants requires targeting both nutritional and nonnutritional modifiable factors specific to stage of hospitalization. Am J Clin Nutr 2019; 110:1384-1394. [PMID: 31536118 PMCID: PMC6885476 DOI: 10.1093/ajcn/nqz227] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 08/16/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Data on how baseline characteristics, acuity, morbidity, and nutrition work in combination to affect the growth of very-low-birth-weight (VLBW, <1500 g) infants are limited. OBJECTIVE We aimed to determine factors associated with in-hospital weight, length, and head circumference (HC) trajectories of VLBW infants. METHODS VLBW infants (n = 316) from the GTA-DoMINO trial were included. Linear mixed-effects models assessed relations of baseline characteristics, acuity (at birth, across hospitalization), major morbidities, and nutrition (enteral feeding type, macronutrient/energy intakes) with changes in anthropometrics over hospitalization (days 1-8, 9-29, 30-75). RESULTS Specific factors and the strength of their associations with growth depended on in-hospital time interval. Small-for-gestational-age infants experienced weight gain (4.3 g · kg-1 · d-1; 95% CI: 2.0, 6.5 g · kg-1 · d-1) during days 1-8, versus weight loss (-4.6 g · kg-1 · d-1; 95% CI: -5.6, -3.7 g · kg-1 · d-1) among appropriate-for-gestational-age infants (P < 0.001). Positive-pressure ventilation (versus oxygen/room air) was associated with slower weight (-1.8 g · kg-1 · d-1) and HC (-0.25 cm/wk) gain during days 9-29 (P < 0.001). Morbidities were negatively associated with growth after days 1-8, with patent ductus arteriosus (PDA) showing negative associations with weight (-2.7 g · kg-1 · d-1), length (-0.11 cm/wk), and HC (-0.21 cm/wk) gain during days 9-29 (P < 0.001). Macronutrient/energy intakes were associated with weight across hospitalization (P ≤ 0.01), with greater weight gain (1.3-3.0 g · kg-1 · d-1) among infants achieving macronutrient/energy recommendations during days 9-29 and 30-75. Macronutrient/energy intakes were associated with HC during the first month (P = 0.013-0.003), with greater HC gain (0.07-0.12 cm/wk) among infants achieving protein, lipid, and energy recommendations during days 9-29. CONCLUSIONS Baseline characteristics, acuity, morbidity, and nutrition factors were independently associated with VLBW infant growth. A focus on achieving macronutrient/energy recommendations and improving nutrient delivery to PDA-diagnosed infants may yield improvements to their growth. This trial was registered at www.isrctn.com as ISRCTN35317141.
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Affiliation(s)
- Michelle R Asbury
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada,Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sharon Unger
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada,Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada,Department of Pediatrics, Mount Sinai Health System, Toronto, Ontario, Canada
| | - Alex Kiss
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada,Evaluative and Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Dawn V Y Ng
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada,Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Yunnie Luk
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada,Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nicole Bando
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rosine Bishara
- Women & Babies Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Christopher Tomlinson
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada,Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada,Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Deborah L O'Connor
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada,Translational Medicine Program, The Hospital for Sick Children, Toronto, Ontario, Canada,Department of Pediatrics, Mount Sinai Health System, Toronto, Ontario, Canada,Address correspondence to DLO (e-mail: )
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21
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Hansson L, Lind T, Wiklund U, Öhlund I, Rydberg A. Fluid restriction negatively affects energy intake and growth in very low birthweight infants with haemodynamically significant patent ductus arteriosus. Acta Paediatr 2019; 108:1985-1992. [PMID: 30980416 DOI: 10.1111/apa.14815] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 04/08/2019] [Accepted: 04/09/2019] [Indexed: 11/27/2022]
Abstract
AIM We explored if fluid restriction in very low birthweight (VLBW) infants with a haemodynamically significant patent ductus arteriosus (PDA) affected energy and protein intakes and growth. METHODS Retrospectively, we identified 90 VLBW infants that were admitted to Umea University Hospital, Sweden, between 2009 and 2012: 42 with and 48 without haemodynamically significant PDA (hsPDA). Anthropometric, fluid, energy and protein intake data during the first 28 days of life were expressed as z-scores. RESULTS In the 42 infants diagnosed with hsPDA, fluid intake was restricted after diagnosis, resulting in a decrease in energy and protein intake. No decrease was observed in the other 48 infants in the cohort. Multivariate analysis showed that the z-score of weight change depended on both ductus arteriosus status and energy intake; thus, infants with hsPDA did not grow as expected with the energy provided to them. CONCLUSION Energy and protein intake was diminished in prematurely born infants with hsPDA when fluid was restricted after diagnosis. The initial reduction in intakes may have contributed to the lower postnatal growth observed in these infants.
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Affiliation(s)
- Lena Hansson
- Department of Clinical Science Paediatrics Umeå University Umeå Sweden
| | - Torbjörn Lind
- Department of Clinical Science Paediatrics Umeå University Umeå Sweden
| | - Urban Wiklund
- Department of Radiation Sciences Biomedical Engineering Umeå University Umeå Sweden
| | - Inger Öhlund
- Department of Clinical Science Paediatrics Umeå University Umeå Sweden
| | - Annika Rydberg
- Department of Clinical Science Paediatrics Umeå University Umeå Sweden
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22
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Adrenal function links to early postnatal growth and blood pressure at age 6 in children born extremely preterm. Pediatr Res 2019; 86:339-347. [PMID: 30631138 PMCID: PMC6561840 DOI: 10.1038/s41390-018-0243-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 11/09/2018] [Indexed: 11/08/2022]
Abstract
BACKGROUND Low birth weight in term-born individuals correlates with adverse cardiometabolic outcomes; excess glucocorticoid exposure has been linked to these relationships. We hypothesized that cortisol and adrenal androgens would correlate inversely with birthweight and directly with markers of cardiometabolic risk in school-aged children born extremely preterm; further, preterm-born would have increased cortisol and adrenal androgens compared to term-born children. METHODS Saliva samples were obtained at age 6 from 219 preterm-born children followed since birth and 40 term-born children and analyzed for dehydroepiandrosterone (DHEA) and cortisol. Cortisol was also measured at home (awakening, 30' later, evening). RESULTS For preterm-born children, cortisol and DHEA correlated inversely with weight and length Z-scores at 36 weeks PMA and positively with systolic BP. DHEA was higher in preterm-born than term-born children (boys p < 0.01; girls p = 0.04). Cortisol was similar between preterm-born and term-born at study visit; however, preterm-born children showed a blunted morning cortisol. In term-born children, DHEA correlated with BMI (p = 0.04), subscapular, and abdominal skinfold thicknesses (both p < 0.01). CONCLUSION Cortisol and DHEA correlated inversely with early postnatal growth and directly with systolic BP in extremely preterm-born children, suggesting perinatal programming. Blunted morning cortisol may reflect NICU stress, as seen after other adverse childhood experiences (ACEs).
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23
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Andrews ET, Ashton JJ, Pearson F, Beattie RM, Johnson MJ. Early postnatal growth failure in preterm infants is not inevitable. Arch Dis Child Fetal Neonatal Ed 2019; 104:F235-F241. [PMID: 30135111 DOI: 10.1136/archdischild-2018-315082] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 06/24/2018] [Accepted: 07/08/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND Previously published data have demonstrated that preterm infants experience a fall across marked centile lines for weight in early life with early poor head growth also reported. This study describes a single neonatal unit's experience of longitudinal change in weight, head circumference (HC) and length in a cohort of preterm infants born <32 weeks' gestation. METHODS Data were collected from a single neonatal unit between July 2012 and June 2017. This period followed the introduction of improved nutritional guidelines. Patients were grouped according to their gestational age at birth. Growth lines were constructed for weight, HC and length in each gestational age group from the median measures and compared with reference centile lines. RESULTS Data were analysed from 396 patients consisting of 2808, 1991 and 2004 measures for weight, HC and length, respectively. Longitudinal growth plots did not show an initial absolute weight loss in any of the subgroups. Across all groups, the mean change in SD score between birth and 36 weeks was -0.27 (95% CI -0.39 to -0.15). CONCLUSIONS This description of longitudinal growth in a cohort of preterm infants demonstrates that early postnatal growth failure is not inevitable, with most infants growing along a trajectory close to their birth centile. There is no evidence of a 2 marked centile line weight decrease or weight loss. These data provide evidence to suggest that extrauterine weight gain tracking centile lines can be achieved.
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Affiliation(s)
- Edward Thomas Andrews
- Department of Neonatal Medicine, Princess Anne Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - James John Ashton
- Department of Paediatric Gastroenterology, Southampton Children's Hospital, Southampton, UK.,Human Genetics and Genomic Medicine, University of Southampton, Southampton, UK
| | - Freya Pearson
- Department of Neonatal Medicine, Princess Anne Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - R Mark Beattie
- Department of Paediatric Gastroenterology, Southampton Children's Hospital, Southampton, UK.,National Institute for Health Research, Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
| | - Mark John Johnson
- Department of Neonatal Medicine, Princess Anne Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,National Institute for Health Research, Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
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24
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Challis P, Larsson L, Stoltz Sjöström E, Serenius F, Domellöf M, Elfvin A. Validation of the diagnosis of necrotising enterocolitis in a Swedish population-based observational study. Acta Paediatr 2019; 108:835-841. [PMID: 30238614 PMCID: PMC6586065 DOI: 10.1111/apa.14585] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 09/17/2018] [Indexed: 12/29/2022]
Abstract
Aim The definition of necrotising enterocolitis (NEC) is based on clinical and radiological signs that can be difficult to interpret. The aim of the present study was to validate the incidence of NEC in the Extremely Preterm Infants in Sweden Study (EXPRESS) Methods The EXPRESS study consisted of all 707 infants born before 27 + 0 gestational weeks during the years 2004–2007 in Sweden. Of these infants, 38 were recorded as having NEC of Bell stage II or higher. Hospital records were obtained for these infants. Furthermore, to identify missed cases, all infants with a sudden reduction of enteral nutrition, in the EXPRESS study were identified (n = 71). Hospital records for these infants were obtained. Thus, 108 hospital records were obtained and scored independently by two neonatologists for NEC. Results Of 38 NEC cases in the EXPRESS study, 26 were classified as NEC after validation. Four cases not recorded in the EXPRESS study were found. The incidence of NEC decreased from 6.3% to 4.3%. Conclusion Validation of the incidence of NEC revealed over‐ and underestimation of NEC in the EXPRESS study despite carefully collected data. Similar problems may occur in other national data sets or quality registers.
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Affiliation(s)
- Pontus Challis
- Department of Clinical Sciences Paediatrics Umeå University Umeå Sweden
| | - Linn Larsson
- Department of Clinical Sciences Paediatrics Umeå University Umeå Sweden
| | | | - Fredrik Serenius
- Department of Clinical Sciences Paediatrics Umeå University Umeå Sweden
- Department of Women's and Children's Health Uppsala University Uppsala Sweden
| | - Magnus Domellöf
- Department of Clinical Sciences Paediatrics Umeå University Umeå Sweden
| | - Anders Elfvin
- Institution of Clinical Sciences Department of Pediatrics Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
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25
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Späth C, Zamir I, Sjöström ES, Domellöf M. Use of Concentrated Parenteral Nutrition Solutions Is Associated With Improved Nutrient Intakes and Postnatal Growth in Very Low-Birth-Weight Infants. JPEN J Parenter Enteral Nutr 2019; 44:327-336. [PMID: 30747444 PMCID: PMC7064909 DOI: 10.1002/jpen.1522] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 01/25/2019] [Indexed: 12/03/2022]
Abstract
Background Evidence showing the beneficial effects of enhanced parenteral nutrition (PN) to very low‐birth‐weight (VLBW, <1500 g) infants is accumulating. However, PN composition and its impact on growth outcomes are questioned. This study aimed to investigate the associations between administration of a concentrated PN regime and intakes of energy and macronutrients as well as postnatal growth in VLBW infants. Methods We compared 2 cohorts of VLBW infants born before (n = 74) and after (n = 44) a concentrated PN regime was introduced into clinical use. Daily nutrition and fluid intake during the first 28 postnatal days and all available growth measurements during hospitalization were retrospectively collected from clinical charts. Results Infants who received concentrated PN compared with original PN had higher parenteral intakes of energy (56 vs 45 kcal/kg/d, P < 0.001), protein (2.6 vs 2.2 g/kg/d, P = 0.008), and fat (1.5 vs 0.7 g/kg/d, P < 0.001) during the first postnatal week. Changes in standard deviation scores for weight and length from birth to postnatal day 28 were more positive in the concentrated PN group (mean [95% CI]; weight change: –0.77 [–1.02 to –0.52] vs –1.29 [–1.33 to –1.05], P = 0.005; length change: –1.01 [–1.36 to –0.65] vs –1.60 [–1.95 to –1.25], P = 0.025). There were no significant differences in fluid intake and infant morbidity between the groups. Conclusion Our results suggest that concentrated PN is useful and seems to be safe for improving early nutrition and growth in VLBW infants.
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Affiliation(s)
- Cornelia Späth
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Itay Zamir
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | | | - Magnus Domellöf
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
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26
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John A, Sun R, Maillart L, Schaefer A, Hamilton Spence E, Perrin MT. Macronutrient variability in human milk from donors to a milk bank: Implications for feeding preterm infants. PLoS One 2019; 14:e0210610. [PMID: 30682200 PMCID: PMC6347243 DOI: 10.1371/journal.pone.0210610] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 12/30/2018] [Indexed: 12/26/2022] Open
Abstract
Background and objective The composition of human milk varies widely and impacts the ability to meet nutrient requirements for preterm infants. The purpose of this study is to use a large dataset of milk composition from donors to a milk bank to: (1) describe the macronutrient variability in human milk and how it contributes to the ability to meet the protein and calorie targets for the preterm infant using fortification with commercially available multi-nutrient fortifiers; (2) assess how temporal versus subject effects explain macronutrient variability; (3) determine how macronutrient variability contributes to the nutrient distribution in pooled donor milk. Methods This is a retrospective, observational study that analyzes the macronutrient data of 1,119 human milk samples from 443 individual donors to a milk bank. We test fortification strategies with potential basic, intermediate, and high protein and calorie commercial fortifiers. Additionally, we simulate the random pooling of multiple donors to model the impact of macronutrient variability on pooled donor milk. Results Fat was the most variable nutrient and accounted for 80% of the difference in calories. A subject-effect predicted more of the variability after 4 weeks postpartum in all macronutrients (R2 > = 0.50) than a time-effect (R2 < = 0.28). When pooling multiple donors, variability was reduced by increasing the number of donors randomly selected for a pool or targeted pooling based on macronutrient analysis of donor pools. Over 75% of mature milk samples fortified with a basic protein fortifier did not meet daily protein targets of 3.5 g/kg without exceeding volumes of 160 ml/kg/day. Conclusion There is a strong individual signature to human milk that impacts the pooling of donor milk, and the ability to meet protein and energy requirements for the preterm infant with basic and intermediate protein and calorie fortifiers.
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Affiliation(s)
- Ashley John
- Department of Industrial Engineering, University of Pittsburgh, Department of Industrial Engineering, Pittsburgh, Pennsylvania, United States of America
| | - Ruichen Sun
- Department of Industrial Engineering, University of Pittsburgh, Department of Industrial Engineering, Pittsburgh, Pennsylvania, United States of America
| | - Lisa Maillart
- Department of Industrial Engineering, University of Pittsburgh, Department of Industrial Engineering, Pittsburgh, Pennsylvania, United States of America
| | - Andrew Schaefer
- Department of Computational and Applied Mathematics, Rice University, Houston, Texas, United States of America
| | | | - Maryanne T. Perrin
- Department of Nutrition, University of North Carolina Greensboro, Greensboro, North Carolina, United States of America
- * E-mail:
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27
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Zamir I, Stoltz Sjöström E, Edstedt Bonamy AK, Mohlkert LA, Norman M, Domellöf M. Postnatal nutritional intakes and hyperglycemia as determinants of blood pressure at 6.5 years of age in children born extremely preterm. Pediatr Res 2019; 86:115-121. [PMID: 30776793 PMCID: PMC6760565 DOI: 10.1038/s41390-019-0341-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 01/16/2019] [Accepted: 02/01/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND Adverse developmental programming by early-life exposures might account for higher blood pressure (BP) in children born extremely preterm. We assessed associations between nutrition, growth and hyperglycemia early in infancy, and BP at 6.5 years of age in children born extremely preterm. METHODS Data regarding perinatal exposures including nutrition, growth and glycemia status were collected from the Extremely Preterm Infants in Sweden Study (EXPRESS), a population-based cohort including infants born <27 gestational weeks during 2004-2007. BP measurements were performed at 6.5 years of age in a sub-cohort of 171 children (35% of the surviving children). RESULTS Higher mean daily protein intake (+1 g/kg/day) during postnatal weeks 1-8 was associated with 0.40 (±0.18) SD higher diastolic BP. Higher mean daily carbohydrate intake (+1 g/kg/day) during the same period was associated with 0.18 (±0.05) and 0.14 (±0.04) SD higher systolic and diastolic BP, respectively. No associations were found between infant growth (weight, length) and later BP. Hyperglycemia and its duration during postnatal weeks 1-4 were associated primarily with higher diastolic BP z-scores. CONCLUSIONS These findings emphasize the importance of modifiable early-life exposures, such as nutrition and hyperglycemia, in determining long-term outcomes in children born extremely preterm.
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Affiliation(s)
- Itay Zamir
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden.
| | | | - Anna-Karin Edstedt Bonamy
- 0000 0004 1937 0626grid.4714.6Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden ,0000 0004 1937 0626grid.4714.6Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden ,0000 0000 8986 2221grid.416648.9Sachs’ Children’s and Youth Hospital, Södersjukhuset, Stockholm, Sweden
| | - Lilly-Ann Mohlkert
- 0000 0000 8986 2221grid.416648.9Sachs’ Children’s and Youth Hospital, Södersjukhuset, Stockholm, Sweden ,0000 0004 1937 0626grid.4714.6Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Mikael Norman
- 0000 0000 8986 2221grid.416648.9Sachs’ Children’s and Youth Hospital, Södersjukhuset, Stockholm, Sweden ,0000 0000 9241 5705grid.24381.3cDepartment of Neonatal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Magnus Domellöf
- 0000 0001 1034 3451grid.12650.30Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
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Wejryd E, Marchini G, Frimmel V, Jonsson B, Abrahamsson T. Probiotics promoted head growth in extremely low birthweight infants in a double-blind placebo-controlled trial. Acta Paediatr 2019; 108:62-69. [PMID: 29999201 DOI: 10.1111/apa.14497] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 06/07/2018] [Accepted: 07/10/2018] [Indexed: 12/28/2022]
Abstract
AIM This study evaluated if oral supplementation with the probiotic bacterium Lactobacillus reuteri DSM 17938 improved enteral feeding tolerance and growth rates in extremely low birthweight (ELBW) infants. METHOD A randomised, double-blind, placebo-controlled trial comprising 134 ELBW (<1000 g) infants born before gestational week 28 + 0. Daily supplementation of L. reuteri (1.25 × 108 bacteria/day) or placebo started within 3 days and continued until gestational week 36 + 0. Primary outcome was feeding tolerance and secondary outcome growth rate calculated as z-score development. RESULTS Feeding tolerance was similar in the probiotic and placebo group. Time to full enteral feeds was 15 days in both groups. The z-score of the head circumference decreased in both groups from birth to day 28 of life, but it decreased less in the L. reuteri group compared to the placebo group: -1.2 SD (95% CI: -1.4 to -1.0) versus -1.7 SD (95% CI: -2.0 to -1.5; p = 0.001). Other growth parameters were similar in the study groups. CONCLUSION Lactobacillus reuteri did not reduce time to reach full enteral feeds in ELBW infants. The L. reuteri supplemented infants, however, had a better growth rate of the head during the first month of life.
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Affiliation(s)
- Erik Wejryd
- Department of Clinical and Experimental Medicine and Department of Pediatrics Linköping University Linköping Sweden
| | - Giovanna Marchini
- Department of Neonatology Astrid Lindgren Children's Hospital Karolinska University Hospital and Institute Stockholm Sweden
| | - Veronica Frimmel
- Department of Neonatology Astrid Lindgren Children's Hospital Karolinska University Hospital Stockholm Sweden
| | - Baldvin Jonsson
- Department of Neonatology Astrid Lindgren Children's Hospital Karolinska University Hospital and Institute Stockholm Sweden
| | - Thomas Abrahamsson
- Department of Clinical and Experimental Medicine and Department of Pediatrics Linköping University Linköping Sweden
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Chan W, Chua MYK, Teo E, Osborn DA, Birch P. Higher versus lower sodium intake for preterm infants. Hippokratia 2017. [DOI: 10.1002/14651858.cd012642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Wendy Chan
- Third Avenue Medical Centre; Brisbane Australia
| | | | - Edward Teo
- Concord Repatriation General Hospital; Emergency Department; Hospital Road Concord Sydney New South Wales Australia 2137
- Griffith University; School of Medicine; Gold Coast Queensland Australia
- The University of Queensland; School of Medicine; Brisbane Queensland Australia
| | - David A Osborn
- University of Sydney; Central Clinical School, Discipline of Obstetrics, Gynaecology and Neonatology; Sydney NSW Australia 2050
| | - Pita Birch
- Gold Coast University Hospital; Newborn Care Unit; 1 Hopsital Boulevard Southport Gold Coast Queensland Australia 4215
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Girardi A, Galletti S, Raschi E, Koci A, Poluzzi E, Faldella G, De Ponti F. Pattern of drug use among preterm neonates: results from an Italian neonatal intensive care unit. Ital J Pediatr 2017; 43:37. [PMID: 28412957 PMCID: PMC5392975 DOI: 10.1186/s13052-017-0354-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 03/30/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Drug use in preterm neonates admitted to Neonatal Intensive Care Unit (NICU) has been investigated, so far, in terms of unauthorized or off-label use; very little is known on the use of combinations of different active substances, which is frequently required in this population (prophylaxis of infections, treatment of concomitant diseases). The aim of this study was to describe the most common patterns of drug use in an Italian NICU, focusing on those with nephrotoxic potential. METHODS Medical records of preterm neonates (<37 weeks of gestational age) weighing less than 1,500 g at birth and admitted to an Italian NICU were scrutinized in a 3-year retrospective investigation. Analysis included drug exposure, duration of therapies, co-administration of drugs with potential renal side effects; also daily protein supplement was calculated from parenteral nutrition. RESULTS A cohort of 159 preterm neonates was selected; 68 were born weighing less than 1,000 g (extremely low birth weight infants, ELBW, Group A), 91 weighed between 1,000 and 1,500 g at birth (Group B). Compared to Group B, neonates of Group A were more likely to receive pharmacological treatments: the most used drugs were antibiotics (especially ampicillin and amikacin, p = .07 and p < .001, respectively), antifungals (especially fluconazole, p < .001), and diuretics (especially furosemide, p < .001). Analysis of co-administration of drugs with potential nephrotoxicity showed ampicillin and amikacin as the most reported combination (94.1% of Group A and 31.9% of Group B), the combination of furosemide with antibacterials (ampicillin or amikacin) was also frequently reported, with average period of combination shorter than 2 days. CONCLUSIONS ELBW infants were exposed to a higher number of drugs compared to other neonates and were more likely to receive associations of drugs with nephrotoxic potential (e.g. furosemide and amikacin), though only for short cycles. Further studies should evaluate the safety profile (especially potential renal side effects) related to most commonly used combinations.
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Affiliation(s)
- A Girardi
- Department of Medical and Surgical Sciences, University of Bologna 40138, Bologna, Italy
| | - S Galletti
- Department of Medical and Surgical Sciences, University of Bologna 40138, Bologna, Italy
| | - E Raschi
- Department of Medical and Surgical Sciences, University of Bologna 40138, Bologna, Italy
| | - A Koci
- Department of Medical and Surgical Sciences, University of Bologna 40138, Bologna, Italy
| | - E Poluzzi
- Department of Medical and Surgical Sciences, University of Bologna 40138, Bologna, Italy
| | - G Faldella
- Department of Medical and Surgical Sciences, University of Bologna 40138, Bologna, Italy
| | - F De Ponti
- Department of Medical and Surgical Sciences, University of Bologna 40138, Bologna, Italy. .,Present Address: Department of Medical and Surgical Sciences, University of Bologna, via Irnerio 48 40126, Bologna, Italy.
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31
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Meyers JM, Bann CM, Stoll BJ, D’Angio CT, Bell EF, Duncan AF, Guillet R. Neurodevelopmental outcomes in postnatal growth-restricted preterm infants with postnatal head-sparing. J Perinatol 2016; 36:1116-1121. [PMID: 27629374 PMCID: PMC5130598 DOI: 10.1038/jp.2016.154] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 08/02/2016] [Accepted: 08/18/2016] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To compare neurodevelopmental outcomes in postnatal growth-restricted infants born <29 weeks with and without postnatal head-sparing (PHS). STUDY DESIGN We analyzed developmental outcomes at 2 years of age among postnatally growth-restricted infants with and without head-sparing. The primary outcome was Bayley III cognitive composite score; secondary outcomes included Bayley III motor composite score, moderate/severe cerebral palsy, gross motor functional classification scale level⩾2, and presence or absence of neurodevelopmental impairment (NDI). RESULTS Of 1098 infants evaluated at 18 to 22 months, 658 were postnatally growth restricted, of whom 301 had head-sparing. In the multivariate model including independent risk factors for poor growth and poor developmental outcome, infants with head-sparing had higher adjusted motor composite scores (mean difference 4.65, P<0.01), but no differences in other neurodevelopmental outcomes. CONCLUSION PHS is associated with improved neurodevelopmental outcome in extremely preterm infants, specifically Bayley III motor scores, but whether beneficial effects of PHS persist later in life is unknown.
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Affiliation(s)
- Jeffrey M. Meyers
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry
| | - Carla M. Bann
- Social, Statistical and Environmental Sciences Unit, RTI International
| | - Barbara J. Stoll
- Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta
| | - Carl T. D’Angio
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry
| | | | - Andrea F. Duncan
- Department of Pediatrics, University of Texas Medical School at Houston
| | - Ronnie Guillet
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry
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32
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Klevebro S, Lundgren P, Hammar U, Smith LE, Bottai M, Domellöf M, Löfqvist C, Hallberg B, Hellström A. Cohort study of growth patterns by gestational age in preterm infants developing morbidity. BMJ Open 2016; 6:e012872. [PMID: 27856479 PMCID: PMC5128893 DOI: 10.1136/bmjopen-2016-012872] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To examine differences in growth patterns in preterm infants developing major morbidities including retinopathy of prematurity (ROP), bronchopulmonary dysplasia (BPD), necrotising enterocolitis (NEC) and intraventricular haemorrhage (IVH). STUDY DESIGN Cohort study of 2521 infants born at a gestational age (GA) of 23-30 weeks from 11 level III neonatal intensive care units in USA and Canada, and 3 Swedish population-based cohorts. OUTCOMES Birth weight and postnatal weight gain were examined relative to birth GA and ROP, BPD, NEC and IVH development. RESULTS Among infants with a birth GA of 25-30 weeks, birth weight SD score and postnatal weight were lower in those developing ROP and BPD. Infants developing ROP showed lower growth rates during postnatal weeks 7-9 in the 23-24 weeks GA group, during weeks 4-6 in the 25-26 weeks GA group and during weeks 1-5 in the 27-30 weeks GA group. Infants with BPD born at 27-30 weeks GA showed lower growth rates during postnatal weeks 3-5. Infants with NEC had lower growth rates after postnatal week 6 in all GA groups, with no significant differences in birth weight SD score. IVH was not associated with prenatal or postnatal growth. CONCLUSIONS In this cohort study of extremely preterm infants, we found that the postnatal growth pattern was associated with morbidities such as ROP, BPD and NEC as well as with gestational age at birth.
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Affiliation(s)
- S Klevebro
- Clinical Sciences, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden
- Sachs' Children and Youth Hospital, South General Hospital, Stockholm, Sweden
| | - P Lundgren
- Department of Ophthalmology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - U Hammar
- Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - L E Smith
- Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - M Bottai
- Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - M Domellöf
- Department of Clinical Sciences, Paediatrics, Umeå University, Umeå, Sweden
| | - C Löfqvist
- Department of Ophthalmology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - B Hallberg
- Clinical Sciences, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Neonatology, Karolinska University Hospital, Stockholm, Sweden
| | - A Hellström
- Department of Ophthalmology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
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33
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Miller M, Donda K, Bhutada A, Rastogi D, Rastogi S. Transitioning Preterm Infants From Parenteral Nutrition: A Comparison of 2 Protocols. JPEN J Parenter Enteral Nutr 2016; 41:1371-1379. [PMID: 27540043 DOI: 10.1177/0148607116664560] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Growth in preterm infants is compromised during the transition phase of nutrition, when parenteral nutrition (PN) volumes are weaned with advancing enteral nutrition (EN) feeds, likely due to suboptimal nutrient intakes during this time. We implemented new PN guidelines designed to maintain optimal nutrient intakes during the transition phase and compared growth outcomes of this cohort with a control group. MATERIALS AND METHODS A chart review was conducted on infants born <32 weeks' gestation, before (control group) and after (study group) a new transition PN protocol was implemented in the neonatal intensive care unit. Weight parameters and nutrient intakes were calculated for the transition phase and compared between the 2 groups. RESULTS Demographic and clinical characteristics of the 2 groups were comparable except for higher rates of sepsis in control group. Weight-for-age z scores at birth, at 1 week of life, and at the start of the transition phase were similar. At the end of the transition phase, infants in the study group had significantly higher z scores compared with the control group, even when corrected for sepsis, a difference that persisted at 35 weeks' gestation. During the transition phase, study infants gained 16.1 ± 4.6 g/kg/d compared with 13.2 ± 5.4 g/kg/d in control group ( P < .001). Similar results were observed in the subset of expressed breastmilk-only fed infants (15.9 ± 4.6 g/kg/d in the study group compared with 13.2 ± 5.4 g/kg/d in the control group, P < .004). CONCLUSION Optimizing nutrition by the use of concentrated PN during the transition phase to maintain appropriate nutrient intakes improves growth rates in preterm infants.
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Affiliation(s)
- Malki Miller
- 1 Department of Nutrition, Maimonides Infants and Children's Hospital, Brooklyn, New York, USA.,2 Division of Neonatology, Maimonides Infants and Children's Hospital, Brooklyn, New York, USA
| | - Keyur Donda
- 2 Division of Neonatology, Maimonides Infants and Children's Hospital, Brooklyn, New York, USA
| | - Alok Bhutada
- 2 Division of Neonatology, Maimonides Infants and Children's Hospital, Brooklyn, New York, USA
| | - Deepa Rastogi
- 3 Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Shantanu Rastogi
- 2 Division of Neonatology, Maimonides Infants and Children's Hospital, Brooklyn, New York, USA
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34
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Cormack BE, Embleton ND, van Goudoever JB, Hay WW, Bloomfield FH. Comparing apples with apples: it is time for standardized reporting of neonatal nutrition and growth studies. Pediatr Res 2016; 79:810-20. [PMID: 26866908 DOI: 10.1038/pr.2016.26] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 12/09/2015] [Indexed: 11/09/2022]
Abstract
The ultimate goal of neonatal nutrition care is optimal growth, neurodevelopment, and long-term health for preterm babies. International consensus is that increased energy and protein intakes in the neonatal period improve growth and neurodevelopment, but after more than 100 y of research the optimum intakes of energy and protein remain unknown. We suggest an important factor contributing to the lack of progress is the lack of a standardized approach to reporting nutritional intake data and growth in the neonatal literature. We reviewed randomized controlled trials and observational studies documented in MEDLINE and the Web of Science from 2008 to 2015 that compared approximately 3 vs. 4 g.kg(-1).d(-1) protein for preterm babies in the first month after birth. Consistency might be expected in the calculation of nutritional intake and assessment of growth outcomes in this relatively narrow scope of neonatal nutrition research. Twenty-two studies were reviewed. There was substantial variation in methods used to estimate and calculate nutritional intakes and in the approaches used in reporting these intakes and measures of infant growth. Such variability makes comparisons amongst studies difficult and meta-analysis unreliable. We propose the StRONNG Checklist-Standardized Reporting Of Neonatal Nutrition and Growth to address these issues.
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Affiliation(s)
- Barbara E Cormack
- Liggins Institute, The University of Auckland, Auckland, New Zealand.,Newborn Services, Auckland City Hospital, Auckland, New Zealand.,Gravida: National Centre for Growth and Development, Auckland, New Zealand.,Auckland Academic Health Alliance, Auckland, New Zealand
| | - Nicholas D Embleton
- Institute of Health and Society, Newcastle University, Newcastle, UK.,Neonatal Unit, Newcastle Hospitals NHS Foundation Trust, Newcastle, UK
| | - Johannes B van Goudoever
- Department of Pediatrics, Emma Children's Hospital/AMC and VU University medical Center, Amsterdam, the Netherlands
| | - William W Hay
- Perinatal Research Center, University of Colorado School of Medicine, Aurora, Colorado
| | - Frank H Bloomfield
- Liggins Institute, The University of Auckland, Auckland, New Zealand.,Newborn Services, Auckland City Hospital, Auckland, New Zealand.,Gravida: National Centre for Growth and Development, Auckland, New Zealand.,Auckland Academic Health Alliance, Auckland, New Zealand
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35
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Stoltz Sjöström E, Lundgren P, Öhlund I, Holmström G, Hellström A, Domellöf M. Low energy intake during the first 4 weeks of life increases the risk for severe retinopathy of prematurity in extremely preterm infants. Arch Dis Child Fetal Neonatal Ed 2016; 101:F108-13. [PMID: 25678632 PMCID: PMC4789715 DOI: 10.1136/archdischild-2014-306816] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 01/10/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Poor weight gain during the first weeks of life in preterm infants is closely associated with the risk of developing the retinopathy of prematurity (ROP) and insufficient nutrition might be an important contributing factor. This study aimed to evaluate the effect of energy and macronutrient intakes during the first 4 weeks of life on the risk for severe ROP (stages 3-5). STUDY DESIGN A population-based study including all Swedish extremely preterm infants born before 27 gestational weeks during a 3-year period. Each infant was classified according to the maximum stage of ROP in either eye as assessed prospectively until full retinal vascularisation. The detailed daily data of actual intakes of enteral and parenteral nutrition and growth data were obtained from hospital records. RESULTS Of the included 498 infants, 172 (34.5%) had severe ROP and 96 (19.3%) were treated. Energy and macronutrient intakes were less than recommended and the infants showed severe postnatal growth failure. Higher intakes of energy, fat and carbohydrates, but not protein, were significantly associated with a lower risk of severe ROP. Adjusting for morbidity, an increased energy intake of 10 kcal/kg/day was associated with a 24% decrease in severe ROP. CONCLUSIONS We showed that low energy intake during the first 4 weeks of life was an independent risk factor for severe ROP. This implies that the provision of adequate energy from parenteral and enteral sources during the first 4 weeks of life may be an effective method for reducing the risk of severe ROP in extremely preterm infants.
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Affiliation(s)
| | - Pia Lundgren
- Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Inger Öhlund
- Department of Clinical Sciences, Paediatrics, Umeå University, Umeå, Sweden
| | - Gerd Holmström
- Department of Neuroscience, Ophthalmology, Uppsala University, Uppsala, Sweden
| | - Ann Hellström
- Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Magnus Domellöf
- Department of Clinical Sciences, Paediatrics, Umeå University, Umeå, Sweden
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36
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George JM, Boyd RN, Colditz PB, Rose SE, Pannek K, Fripp J, Lingwood BE, Lai MM, Kong AHT, Ware RS, Coulthard A, Finn CM, Bandaranayake SE. PPREMO: a prospective cohort study of preterm infant brain structure and function to predict neurodevelopmental outcome. BMC Pediatr 2015; 15:123. [PMID: 26377791 PMCID: PMC4572671 DOI: 10.1186/s12887-015-0439-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 09/01/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND More than 50 percent of all infants born very preterm will experience significant motor and cognitive impairment. Provision of early intervention is dependent upon accurate, early identification of infants at risk of adverse outcomes. Magnetic resonance imaging at term equivalent age combined with General Movements assessment at 12 weeks corrected age is currently the most accurate method for early prediction of cerebral palsy at 12 months corrected age. To date no studies have compared the use of earlier magnetic resonance imaging combined with neuromotor and neurobehavioural assessments (at 30 weeks postmenstrual age) to predict later motor and neurodevelopmental outcomes including cerebral palsy (at 12-24 months corrected age). This study aims to investigate i) the relationship between earlier brain imaging and neuromotor/neurobehavioural assessments at 30 and 40 weeks postmenstrual age, and ii) their ability to predict motor and neurodevelopmental outcomes at 3 and 12 months corrected age. METHODS/DESIGN This prospective cohort study will recruit 80 preterm infants born ≤ 30 week's gestation and a reference group of 20 healthy term born infants from the Royal Brisbane & Women's Hospital in Brisbane, Australia. Infants will undergo brain magnetic resonance imaging at approximately 30 and 40 weeks postmenstrual age to develop our understanding of very early brain structure at 30 weeks and maturation that occurs between 30 and 40 weeks postmenstrual age. A combination of neurological (Hammersmith Neonatal Neurologic Examination), neuromotor (General Movements, Test of Infant Motor Performance), neurobehavioural (NICU Network Neurobehavioural Scale, Premie-Neuro) and visual assessments will be performed at 30 and 40 weeks postmenstrual age to improve our understanding of the relationship between brain structure and function. These data will be compared to motor assessments at 12 weeks corrected age and motor and neurodevelopmental outcomes at 12 months corrected age (neurological assessment by paediatrician, Bayley scales of Infant and Toddler Development, Alberta Infant Motor Scale, Neurosensory Motor Developmental Assessment) to differentiate atypical development (including cerebral palsy and/or motor delay). DISCUSSION Earlier identification of those very preterm infants at risk of adverse neurodevelopmental and motor outcomes provides an additional period for intervention to optimise outcomes. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12613000280707. Registered 8 March 2013.
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Affiliation(s)
- Joanne M George
- Queensland Cerebral Palsy and Rehabilitation Research Centre, School of Medicine, Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane, Australia.
| | - Roslyn N Boyd
- Queensland Cerebral Palsy and Rehabilitation Research Centre, School of Medicine, Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane, Australia.
- Queensland Paediatric Rehabilitation Service, Lady Cilento Children's Hospital, Brisbane, Australia.
| | - Paul B Colditz
- University of Queensland Centre for Clinical Research, Faculty of Medicine and Biomedical Sciences, The University of Queensland, Royal Brisbane and Women's Hospital, Brisbane, Australia.
| | - Stephen E Rose
- Digital Productivity Flagship, The Australian e-Health Research Centre, CSIRO, Brisbane, Australia.
| | - Kerstin Pannek
- Queensland Cerebral Palsy and Rehabilitation Research Centre, School of Medicine, Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane, Australia.
- Digital Productivity Flagship, The Australian e-Health Research Centre, CSIRO, Brisbane, Australia.
| | - Jurgen Fripp
- Digital Productivity Flagship, The Australian e-Health Research Centre, CSIRO, Brisbane, Australia.
| | - Barbara E Lingwood
- University of Queensland Centre for Clinical Research, Faculty of Medicine and Biomedical Sciences, The University of Queensland, Royal Brisbane and Women's Hospital, Brisbane, Australia.
| | - Melissa M Lai
- University of Queensland Centre for Clinical Research, Faculty of Medicine and Biomedical Sciences, The University of Queensland, Royal Brisbane and Women's Hospital, Brisbane, Australia.
| | - Annice H T Kong
- University of Queensland Centre for Clinical Research, Faculty of Medicine and Biomedical Sciences, The University of Queensland, Royal Brisbane and Women's Hospital, Brisbane, Australia.
| | - Robert S Ware
- School of Population Health, The University of Queensland, Brisbane, Australia.
- Queensland Children's Medical Research Institute, Children's Health Queensland Hospitals and Health Service, Brisbane, Australia.
| | - Alan Coulthard
- Royal Brisbane and Women's Hospital, Brisbane, Australia.
- Academic Discipline of Medical Imaging, School of Medicine, Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane, Australia.
| | - Christine M Finn
- Queensland Cerebral Palsy and Rehabilitation Research Centre, School of Medicine, Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane, Australia.
| | - Sasaka E Bandaranayake
- Queensland Paediatric Rehabilitation Service, Lady Cilento Children's Hospital, Brisbane, Australia.
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