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Perrin T, Pradat P, Larcade J, Masclef-Imbert M, Pastor-Diez B, Picaud JC. Postnatal growth and body composition in extremely low birth weight infants fed with individually adjusted fortified human milk: a cohort study. Eur J Pediatr 2023; 182:1143-1154. [PMID: 36598567 PMCID: PMC10023649 DOI: 10.1007/s00431-022-04775-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 12/19/2022] [Accepted: 12/21/2022] [Indexed: 01/05/2023]
Abstract
This cohort study aimed to evaluate the impact of an individualised nutritional care approach combining standardised fortification with adjustable fortification on postnatal growth and body composition in extremely low birth weight (ELBW) infants. We included ELBW infants admitted to a neonatal intensive care unit and still hospitalised at 35 weeks postmenstrual age (PMA). The fortification of human milk was standardised (multicomponent fortifier) between 70 mL/kg/day and full enteral feeding, and then individualised using adjustable fortification. When weight gain was below 20 g/kg/day, protein or energy was added when serum urea was below or above 3.5 mmol/L, respectively. Postnatal growth failure (PNGF) was defined as being small for gestational age at discharge and/or when the Z-score loss between birth and discharge was higher than 1. Body composition was assessed between 35 and 41 weeks of PMA. Among the 310 ELBW infants included, the gestational age of birth was 26.7 ± 1.8 weeks, and the birth weight was 800 ± 128 g. The mean Z-score difference between birth and discharge was moderately negative for the weight (-0.32), more strongly negative for length (-1.21), and almost nil for head circumference (+ 0.03). Only 27% of infants presented PNGF. At discharge, fat mass was 19.8 ± 3.6%. Multivariable analysis showed that the proportion of preterm formula received and gestational age at birth were independently associated with the percentage of fat mass. Conclusion: The individualised nutritional care approach applied herein prevented postnatal weight loss in most infants, limited length growth deficit, and supported excellent head circumference growth. What is Known: • At least half of extremely low birth weight infants are small for gestational age at discharge and postnatal growth deficit has been associated with impaired neurocognitive and renal development. • Human milk is the main milk used in neonatology and, although fortification of human milk is a standard of care, there is no consensus regarding the optimal fortification strategy to be adopted. What is New: • Using an approach combining standardised fortification followed by individualised adjustable fortification limited postnatal growth deficit for body weight and head circumference. Postnatal growth failure is not a fatality in extremely low birth weight infants. • Each additional gestational age week at birth resulted in a decrease in fat mass percentage at discharge, which was higher than in foetuses of the same gestational age, likely representing a necessary adaptation to extra-uterine life.
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Affiliation(s)
- Tania Perrin
- Service de Néonatologie, Hospices Civils de Lyon, Hôpital Universitaire de La Croix-Rousse, 103 Grande Rue de La Croix-Rousse, 69004, Lyon, 69677, France
| | - Pierre Pradat
- Centre de Recherche Clinique, Hospices Civils de Lyon, Hôpital Universitaire de La Croix-Rousse, Lyon, 69004, France
| | - Julie Larcade
- Service de Néonatologie, Hospices Civils de Lyon, Hôpital Universitaire de La Croix-Rousse, 103 Grande Rue de La Croix-Rousse, 69004, Lyon, 69677, France
| | - Marion Masclef-Imbert
- Service de Néonatologie, Hospices Civils de Lyon, Hôpital Universitaire de La Croix-Rousse, 103 Grande Rue de La Croix-Rousse, 69004, Lyon, 69677, France
| | - Blandine Pastor-Diez
- Service de Néonatologie, Hospices Civils de Lyon, Hôpital Universitaire de La Croix-Rousse, 103 Grande Rue de La Croix-Rousse, 69004, Lyon, 69677, France
| | - Jean-Charles Picaud
- Service de Néonatologie, Hospices Civils de Lyon, Hôpital Universitaire de La Croix-Rousse, 103 Grande Rue de La Croix-Rousse, 69004, Lyon, 69677, France.
- Laboratoire CarMen, INSERM, INRA, Université Claude Bernard Lyon1, Pierre-Bénite, Lyon, 69310, France.
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Hilditch C, Keir A, Collins CT, Middleton P, Gomersall J. Early versus delayed introduction of human milk fortification in enterally fed preterm infants: A systematic review and meta-analysis. J Paediatr Child Health 2022; 58:30-38. [PMID: 34669996 DOI: 10.1111/jpc.15810] [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: 10/31/2020] [Revised: 06/15/2021] [Accepted: 10/05/2021] [Indexed: 01/18/2023]
Abstract
AIM To assess effects of early versus delayed introduction of human milk fortification in preterm infants. METHODS We searched Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PubMed and CINAHL for randomised controlled trials evaluating start time for human milk fortification in preterm infants (March 2020). Two authors assessed trial eligibility and risk of bias, extracted data and assessed evidence certainty. RESULTS We identified 1307 publications and included three trials (378 infants). Meta-analysis comparing fortification commencing at an enteral feed volume of ≤40 mL/kg/day versus ≥75 mL/kg/day, showed little to no difference in rates of necrotising enterocolitis (3 trials), sepsis (3 trials), feeding intolerance (2 trials) (low-quality evidence) and infant growth (1 trial, very low-quality evidence). CONCLUSIONS Whether early introduction of fortification, at an enteral feed volume of ≤40 mL versus delayed at ≥75 mL/kg/day improves growth or influences adverse feeding outcomes is very uncertain.
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Affiliation(s)
- Cathie Hilditch
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia.,Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia.,Women's and Children's Health Network, Adelaide, South Australia, Australia
| | - Amy Keir
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia.,Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia.,Women's and Children's Health Network, Adelaide, South Australia, Australia
| | - Carmel T Collins
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Philippa Middleton
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia.,Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Judith Gomersall
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,School of Public Health, The University of Adelaide, Adelaide, South Australia, Australia
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Preterm infant meconium microbiota transplant induces growth failure, inflammatory activation, and metabolic disturbances in germ-free mice. Cell Rep Med 2021; 2:100447. [PMID: 34841294 PMCID: PMC8606908 DOI: 10.1016/j.xcrm.2021.100447] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 06/17/2021] [Accepted: 10/19/2021] [Indexed: 12/13/2022]
Abstract
Preterm birth may result in adverse health outcomes. Very preterm infants typically exhibit postnatal growth restriction, metabolic disturbances, and exaggerated inflammatory responses. We investigated the differences in the meconium microbiota composition between very preterm (<32 weeks), moderately preterm (32–37 weeks), and term (>37 weeks) human neonates by 16S rRNA gene sequencing. Human meconium microbiota transplants to germ-free mice were conducted to investigate whether the meconium microbiota is causally related to the preterm infant phenotype in an experimental model. Our results indicate that very preterm birth is associated with a distinct meconium microbiota composition. Fecal microbiota transplant of very preterm infant meconium results in impaired growth, altered intestinal immune function, and metabolic parameters as compared to term infant meconium transplants in germ-free mice. This finding suggests that measures aiming to minimize the long-term adverse consequences of very preterm birth should be commenced during pregnancy or directly after birth. Very preterm neonates exhibit a distinct meconium microbiota composition Human meconium microbiota is transplanted to germ-free mice in this study Preterm transplant induces growth restriction, inflammation, and altered metabolism Initial gut microbiota may be causally related to complications of prematurity
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Talbo MK, Besner ME, Plourde H, Claveau M, Beltempo M. Association of Caloric Intake, Protein Intake, and Enteral Feeding Initiation with Weight Gain in Infants Born 32 to 34 Weeks' Gestation. Am J Perinatol 2020; 37:1228-1233. [PMID: 31238346 DOI: 10.1055/s-0039-1692717] [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] [Indexed: 10/26/2022]
Abstract
OBJECTIVE This study aimed to determine the association of caloric intake, protein intake, and enteral feed initiation time in the first 3 days of life with weight loss percentage (%WL) at 7 days among infants born 32 to 34 weeks' gestational age (GA). STUDY DESIGN This is a retrospective cohort study of 252 infants admitted to a neonatal intensive care unit. Patient data included patient characteristics, daily weight, intake, and method of nutrition in the first 3 days. Multivariate linear regression was used to explore associations between outcome (%WL at day 7 of life) and exposures (caloric intake, protein intake, and enteral feed initiation time) and adjusted for covariates (GA, birth weight, and sex). RESULTS Median 7 days %WL was 2.3% (interquartile range: -5.2, 1.2). Average caloric intake and average protein intake in the first 3 days were 57 kcal/kg/d and 2.3 g/kg/d. In the adjusted linear regression, caloric intake and protein intake (coefficient = 0.03, 95% confidence interval [CI]: -0.06, 0.09 and coefficient = 0.11, 95% CI: -0.36, 2.30) were not associated with %WL at 7 days. Enteral feeds ≤12 hours were associated with less %WL at 7 days of life (Coef = -0.15, 95% CI: -2.67, -0.17). CONCLUSION Enteral feeds ≤12 hours after delivery is associated with lower %WL at 7 days among preterm infants 32 to 34 weeks' GA.
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Affiliation(s)
- Meryem Khadija Talbo
- School of Human Nutrition, Faculty of Agricultural and Environmental Sciences, McGill University, Montreal, Quebec, Canada
| | - Marie-Eve Besner
- Department of Clinical Nutrition, Montreal Children's Hospital, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Hugues Plourde
- School of Human Nutrition, Faculty of Agricultural and Environmental Sciences, McGill University, Montreal, Quebec, Canada
| | - Martine Claveau
- Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Marc Beltempo
- Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
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Thanigainathan S, Abiramalatha T. Early fortification of human milk versus late fortification to promote growth in preterm infants. Cochrane Database Syst Rev 2020; 7:CD013392. [PMID: 32726863 PMCID: PMC7390609 DOI: 10.1002/14651858.cd013392.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Uncertainty exists about the optimal point at which multi-component fortifier should be added to human milk for promoting growth in preterm infants. The most common practice is to start fortification when the infant's daily enteral feed volume reaches 100 mL/kg body weight. Another approach is to commence fortification earlier, in some cases as early as the first enteral feed. Early fortification of human milk could increase nutrient intake and growth rates but may increase the risk of feed intolerance and necrotising enterocolitis (NEC). OBJECTIVES To assess effects on growth and safety of early fortification of human milk versus late fortification in preterm infants To assess whether effects vary based upon gestational age (≤ 27 weeks; 28 to 31 weeks; ≥ 32 weeks), birth weight (< 1000 g; 1000 to 1499 g; ≥ 1500 g), small or appropriate for gestational age, or type of fortifier (bovine milk-based human milk fortifier (HMF); human milk-based HMF; formula powder) SEARCH METHODS: We used the standard strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 8); OVID MEDLINE (R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions (R) (1946 to 15 August 2019); MEDLINE via PubMed (1 August 2018 to 15 August 2019) for the previous year; and the Cumulative Index to Nursing and Allied Health Literatue (CINAHL) (1981 to 15 August 2019). We searched clinical trials databases and reference lists of included studies. SELECTION CRITERIA We included randomised controlled trials that compared early versus late fortification of human milk in preterm infants. We defined early fortification as fortification started at < 100 mL/kg/d enteral feed volume or < 7 days postnatal age, and late fortification as fortification started at ≥ 100 mL/kg/d feeds or ≥ 7 days postnatal age. DATA COLLECTION AND ANALYSIS Both review authors assessed trial eligibility and risk of bias and independently extracted data. We analysed treatment effects in individual trials, and we reported risk ratio (RR) for dichotomous data and mean difference (MD) for continuous data, with respective 95% confidence intervals (CIs). We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS We included two trials with a total of 237 infants. All participants were very low birth weight infants (birth weight < 1500 g). Early fortification was started at 20 mL/kg/d enteral feeds in one study and 40 mL/kg/d in the other study. Late fortification was started at 100 mL/kg/d feeds in both studies. One study used bovine milk-based fortifier, and the other used human milk-based fortifier. Meta-analysis showed that early fortification may have little or no effect on growth outcomes including time to regain birth weight (MD -0.06 days, 95% CI -1.32 to 1.20 days), linear growth (MD 0.10 cm/week, 95% CI -0.03 to 0.22 cm/week), or head growth (MD -0.01 cm/week, 95% CI -0.07 to 0.06 cm/week) during the initial hospitalisation period. Early fortification may have little or no effect on the risk of NEC (MD -0.01, 95% CI -0.07 to 0.06). The certainty of evidence was low for these outcomes due to risk of bias (lack of blinding) and imprecision (small sample size). Early fortification may have little or no effect on incidence of surgical NEC, time to reach full enteral feeds, extrauterine growth restriction at discharge, proportion of infants with feed interruption episodes, duration of total parenteral nutrition (TPN), duration of central venous line usage, or incidence of invasive infection, all-cause mortality, and duration of hospital stay. The certainty of evidence was low for these outcomes due to risk of bias (lack of blinding) and imprecision (small sample size). We did not have data for other outcomes such as subsequent weight gain after birth weight is regained, parenteral nutrition-associated liver disease, postdischarge growth, and neurodevelopmental outcomes. AUTHORS' CONCLUSIONS Available evidence is insufficient to support or refute early fortification of human milk in preterm infants. Further large trials would be needed to provide data of sufficient quality and precision to inform policy and practice.
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Affiliation(s)
- Sivam Thanigainathan
- Neonatology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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Basu S, Upadhyay J, Singh P, Kumar M. Early versus late fortification of breast milk in preterm infants: a systematic review and meta-analysis. Eur J Pediatr 2020; 179:1057-1068. [PMID: 32458060 DOI: 10.1007/s00431-020-03677-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/20/2020] [Accepted: 05/06/2020] [Indexed: 11/29/2022]
Abstract
This systematic review and meta-analysis assessed the effects of early fortification (EF) versus late fortification (LF) of breast milk (BM) on growth of preterm infants. Randomized and quasi-randomized controlled trials (RCTs) dealing with the effects of EF versus LF on growth parameters, incidence of adverse events, and duration of hospital stay in preterm infants were included. Data were pooled using the RevMan 5.3 software. Quality of evidence for predefined outcomes was analyzed by GRADE. Available evidence (3 RCTs, 309 preterm infants) showed no statistically significant difference between EF and LF of BM for any of the growth parameters-weight (standardized mean difference (SMD) 0.13; 95% confidence interval (CI) - 0.09, 0.36); length (SMD 0.02; 95% CI - 0.20, 0.25); and head circumference (SMD - 0.10; 95% CI - 0.33, 0.12). Total parenteral nutrition days were similar. Duration of hospital stay was significantly higher with EF (MD 4.29; 95% CI 0.84, 7.75) with a trend of non-significant increase in feed intolerance and necrotizing enterocolitis (NEC).Conclusion: Very low quality evidence did not find any significant difference in growth parameters of preterm infants in association with EF or LF of BM. A significant increase in hospital stay and non-significant increase in feed intolerance and NEC were associated with EF.PROSPERO registration number: CRD42019139235What is Known:• Fortification of breast milk with essential macro- and micronutrients is necessary for optimization of nutrition in preterm infants.• There is no consensus regarding the breast milk feeding volume at which fortification should be initiated.What is New:• Very low quality evidence showed no significant difference between early and late fortification of breast milk on growth parameters of preterm infants.• Early fortification was associated with non-significant increase in feed intolerance and necrotizing enterocolitis and a significant increase in hospital stay.
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Affiliation(s)
- Sriparna Basu
- Department of Neonatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India.
| | - Jaya Upadhyay
- Department of Neonatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Poonam Singh
- Department of Neonatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Manish Kumar
- Department of Pediatrics, All India Institute of Medical Sciences, Gorakhpur, India
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7
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Levene I, McCormick K. Improved growth of extremely and very preterm babies: Evaluation of a quality-of-care initiative. J Paediatr Child Health 2020; 56:444-449. [PMID: 31774596 DOI: 10.1111/jpc.14662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 08/29/2019] [Accepted: 09/09/2019] [Indexed: 11/28/2022]
Abstract
AIM To measure growth outcomes in preterm infants after introduction of a nutritional care bundle. METHODS A total of 509 infants of less than 32 weeks' gestation in a level III neonatal intensive care unit in the UK were studied until they were discharged home. Growth and feeding data were extracted from a prospective data registry for 18 months before and after the intervention. The intervention consisted of earlier routine bovine-derived multi-component fortification once the infant has reached 120ml/kg/day of enteral feed from the first day of life and an exclusive human milk diet with routine bovine-derived multi-component fortification of 120 mL/kg/day. RESULTS After the intervention, growth velocity between birth and 28 days increased from 9.7 ± 4.1 to 12.2 ± 4.6 g/kg/day (mean ± standard deviation), and weight z score change decreased from -1.06 ± 0.56 to -0.76 ± 0.59 (P < 0.00002). For the entire group, growth velocity by the discharge home time point increased by 1 g/kg/day. However, the growth velocity of infants who were discharged on an exclusive human milk diet increased the most, from 10.8 ± 2.2 to 13.0 ± 2.8 g/kg/day (P < 0.00001), eliminating the difference seen between these infants and those discharged on infant formula before the intervention. CONCLUSION The introduction of a simple nutritional package improved weight gain, particularly in infants fed exclusive human milk at discharge.
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Affiliation(s)
- Ilana Levene
- Newborn Care Unit, John Radcliffe Hospital, Oxford, United Kingdom
| | - Kenny McCormick
- Newborn Care Unit, John Radcliffe Hospital, Oxford, United Kingdom
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8
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Kaplan O, Wainstock T, Sheiner E, Staretz-Chacham O, Walfisch A. Maternal anemia and offspring failure to thrive - results from a large population-based cohort. J Matern Fetal Neonatal Med 2019; 34:3889-3895. [PMID: 31847635 DOI: 10.1080/14767058.2019.1702018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Objective: To evaluate whether an association exists between maternal anemia and offspring failure to thrive (FTT) during childhood.Methods: A population-based cohort analysis was performed, comparing the risk for FTT among children (up to 18 years old) based on maternal hemoglobin (Hb) levels, upon postpartum discharge. Maternal Hb levels were categorized into 3 levels: <9.0 (moderate-severe anemia), 9.0-11.0 (mild anemia), and ≥11.0 g/dL (no anemia). FTT diagnosis was based on hospital records. All singletons born between 1991 and 2014 and discharged alive without congenital malformations were included. A survival curve was constructed to compare the cumulative FTT incidence, and a Weibull parametric survival analysis to assess the independent association between maternal anemia and offspring FTT while controlling for confounders.Results: Of the 214,305 included deliveries, 22,071 parturients (10.3%) were discharged with Hb <9.00; 83,932 (39.2%) with Hb between 9.0-11.0; and 108,302 (50.5%) with Hb ≥11.0 g/dL. FTT rates were 1.3% (n = 287), 1.2% (n = 967), and 1.1% (n = 1141) in the same groups, respectively (p = .003). The survival curve demonstrated a significantly higher cumulative incidence of FTT diagnosis in the moderate-severe maternal anemia group (p < .001). In the Weibull analysis, constructed for newborns with appropriate birthweight, both groups of maternal anemia were found to be independently associated with FTT related hospitalizations (mild anemia aHR, 1.1; 95%CI 1.002-1.219; p = .045, moderate-severe anemia aHR, 1.321; 95%CI, 1.141-1.529; p < .001).Conclusion: Maternal anemia is independently associated with long-term FTT in offspring, with increasing FTT rates proportional to anemia severity.
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Affiliation(s)
- Omer Kaplan
- Faculty of Health Sciences, Goldman Medical School, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Tamar Wainstock
- Department of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Eyal Sheiner
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Orna Staretz-Chacham
- Department of Neonatology, Metabolic clinic, Soroka University Medical Center, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Asnat Walfisch
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben-Gurion University of the Negev, Be'er Sheva, Israel
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Abstract
Proteins are key structural components of all human cells and are also involved in key physiologic processes through their roles as enzymes, hormones and transport proteins. Protein requirements are substantially higher in preterm infants than those born at term, yet inadequate protein intakes are a common problem on many neonatal units. Very preterm infants (VPT, <32 weeks) commonly receive parenteral amino acid solutions which are typically commenced on admission, and increased over the next few days. Several recent studies have explored differing parenteral amino acid intakes in the first few days, and recommendations have recently been updated. Parenteral nutrition intakes are decreased as enteral feeds are tolerated, but human milk alone will not meet protein needs in most VPT and supplementation or fortification will be required. This review paper considers basic protein and amino acid physiology in the newborn period, and the evidence base for current recommendations.
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Affiliation(s)
- Nicholas D Embleton
- Newcastle Neonatal Service, Newcastle Hospitals NHS Trust, Newcastle upon Tyne, UK.
| | - Chris H P van den Akker
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Pediatrics - Neonatology, Amsterdam, The Netherlands
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10
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Godden B, Collins CT, Hilditch C, McLeod G, Keir A. Does early compared to late fortification of human milk for preterm infants improve clinical outcomes? J Paediatr Child Health 2019; 55:867-872. [PMID: 31270869 DOI: 10.1111/jpc.14499] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 04/25/2019] [Accepted: 04/30/2019] [Indexed: 11/29/2022]
Abstract
AIM This evidence-based review aims to answer the following structured clinical question: In preterm infants <37 weeks' gestation (patient), does early fortification of breast milk (intervention) compared to late fortification (control) improve growth outcomes at the time of discharge or affect length of hospital stay (outcome)? METHODS MEDLINE, Embase, Maternity and Infant Care Database and Evidence-Based Medicine Reviews were searched for articles published from 2000 onwards that were relevant to the structured clinical question. The National Institute for Health and Care Excellence, National Health and Medical Research Council, Agency for Healthcare Research and Quality, National Institute of Health and Turning Research into Practice databases were also searched, and reference lists of relevant articles were reviewed. RESULTS A total of 167 articles, after removal of duplicates, were found and screened by title and abstract. Five full-text articles were ultimately included in the review. CONCLUSIONS The results of this review suggest that early fortification is safe and well tolerated. However, earlier fortification has not been shown to have a significant impact on growth outcomes at time of discharge or length of stay. More research is required to determine if early fortification of breast milk may have benefits regarding longer-term growth and neurodevelopmental outcomes.
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Affiliation(s)
- Beth Godden
- Department of Neonatal Medicine, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Carmel T Collins
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Cathie Hilditch
- Department of Neonatal Medicine, Women's and Children's Hospital, Adelaide, South Australia, Australia.,SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Gemma McLeod
- Centre for Neonatal Research and Education, University of Western Australia, Perth, Western Australia, Australia.,Women and Newborn Health Service, King Edward Memorial and Princess Margaret Hospitals, Perth, Western Australia, Australia
| | - Amy Keir
- Department of Neonatal Medicine, Women's and Children's Hospital, Adelaide, South Australia, Australia.,SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia.,Robinson Research Institute, University of Adelaide, Adelaide, South Australia, Australia
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11
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Arslanoglu S, Boquien CY, King C, Lamireau D, Tonetto P, Barnett D, Bertino E, Gaya A, Gebauer C, Grovslien A, Moro GE, Weaver G, Wesolowska AM, Picaud JC. Fortification of Human Milk for Preterm Infants: Update and Recommendations of the European Milk Bank Association (EMBA) Working Group on Human Milk Fortification. Front Pediatr 2019; 7:76. [PMID: 30968003 PMCID: PMC6439523 DOI: 10.3389/fped.2019.00076] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 02/25/2019] [Indexed: 01/03/2023] Open
Abstract
Evidence indicates that human milk (HM) is the best form of nutrition uniquely suited not only to term but also to preterm infants conferring health benefits in both the short and long-term. However, HM does not provide sufficient nutrition for the very low birth weight (VLBW) infant when fed at the usual feeding volumes leading to slow growth with the risk of neurocognitive impairment and other poor health outcomes such as retinopathy and bronchopulmonary dysplasia. HM should be supplemented (fortified) with the nutrients in short supply, particularly with protein, calcium, and phosphate to meet the high requirements of this group of babies. In this paper the European Milk Bank Association (EMBA) Working Group on HM Fortification discusses the existing evidence in this field, gives an overview of different fortification approaches and definitions, outlines the gaps in knowledge and gives recommendations for practice and suggestions for future research. EMBA recognizes that "Standard Fortification," which is currently the most utilized regimen in neonatal intensive care units, still falls short in supplying sufficient protein for some VLBW infants. EMBA encourages the use of "Individualized Fortification" to optimize nutrient intake. "Adjustable Fortification" and "Targeted Fortification" are 2 methods of individualized fortification. The quality and source of human milk fortifiers constitute another important topic. There is work looking at human milk derived fortifiers, but it is still too early to draw precise conclusions about their use. The pros and cons are discussed in this Commentary in addition to the evidence around use of fortifiers post discharge.
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Affiliation(s)
- Sertac Arslanoglu
- Division of Neonatology, Department of Pediatrics, Istanbul Medeniyet University, Istanbul, Turkey
| | - Clair-Yves Boquien
- PhAN, Institut National de la Recherche Agronomique (INRA), Université de Nantes, CRNH-Ouest, Nantes, France
| | - Caroline King
- Department of Nutrition and Dietetics, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Delphine Lamireau
- Lactariums de Bordeaux-Marmande, Pôle Pédiatrique, Centre Hospitalo-Universitaire (CHU) de Bordeaux, Bordeaux, France
| | - Paola Tonetto
- Neonatal Unit of Turin University, City of Health and Science of Turin, Turin, Italy
| | - Debbie Barnett
- Greater Glasgow and Clyde Donor Milk Bank, Royal Hospital for Sick Children, Glasgow, United Kingdom
| | - Enrico Bertino
- Neonatal Unit of Turin University, City of Health and Science of Turin, Turin, Italy
| | - Antoni Gaya
- Banc de Teixits, Fundaciò Banc Sang i Teixits de les Illes Balears, Palma de Mallorca, Spain
| | - Corinna Gebauer
- Abteilung Neonatologie Klinik und Poliklinik für Kinder und Jugendliche, Leipzig, Germany
| | - Anne Grovslien
- Neonatal Unit, Milk Bank, Oslo University Hospital, Oslo, Norway
| | - Guido E Moro
- Associazione Italiana Banche del Latte Umano Donato (AIBLUD), Milan, Italy
| | - Gillian Weaver
- Hearts Milk Bank, Rothamsted Research Institute, Harpenden, United Kingdom
| | | | - Jean-Charles Picaud
- CarMeN Unit, INSERM U1060, INRA U1397, Claude Bernard University Lyon 1, Pierre Bénite, France.,Division of Neonatology, Hôpital de la Croix-Rousse, Lyon, France
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12
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Darmaun D, Lapillonne A, Simeoni U, Picaud JC, Rozé JC, Saliba E, Bocquet A, Chouraqui JP, Dupont C, Feillet F, Frelut ML, Girardet JP, Turck D, Briend A. Parenteral nutrition for preterm infants: Issues and strategy. Arch Pediatr 2018; 25:286-294. [PMID: 29656825 DOI: 10.1016/j.arcped.2018.02.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 01/26/2018] [Accepted: 02/18/2018] [Indexed: 01/13/2023]
Abstract
Due to transient gut immaturity, most very preterm infants receive parenteral nutrition (PN) in the first few weeks of life. Yet providing enough protein and energy to sustain optimal growth in such infants remains a challenge. Extrauterine growth restriction is frequently observed in very preterm infants at the time of discharge from hospital, and has been found to be associated with later impaired neurodevelopment. A few recent randomized trials suggest that intensified PN can improve early growth; whether or not such early PN improves long-term neurological outcome is still unclear. Several other questions regarding what is optimal PN for very preterm infants remain unanswered. Amino acid mixtures designed for infants contain large amounts of branched-chain amino acids and taurine, but there is no consensus on the need for some nonessential amino acids such as glutamine, arginine, and cysteine. Whether excess growth in the first few weeks of life, at a time when very preterm infants receive PN, has an imprinting effect, increasing the risk of metabolic or vascular disease at adulthood continues to be debated. Even though uncertainty remains regarding the long-term effect of early PN, it appears reasonable to propose intensified initial PN. The aim of the current position paper is to review the evidence supporting such a strategy with regards to the early phase of nutrition, which is mainly covered by parenteral nutrition. More randomized trials are, however, needed to further support this type of approach and to demonstrate that this strategy improves short- and long-term outcome.
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Affiliation(s)
- D Darmaun
- Université Nantes-Atlantique, 44300 Nantes, France.
| | | | - U Simeoni
- Université de Lausanne, CHUV, 1011 Lausanne, Suisse
| | - J-C Picaud
- Université Claude-Bernard-Lyon 1, 69008 Lyon, France
| | - J-C Rozé
- Université Nantes-Atlantique, 44300 Nantes, France
| | - E Saliba
- Université François-Rabelais, 37000 Tours, France
| | - A Bocquet
- Université de Franche-Comté, 25000 Besançon, France
| | | | - C Dupont
- Université Paris Descartes, 75006 Paris, France
| | - F Feillet
- Université de Lorraine, 54000 Nancy, France
| | - M-L Frelut
- Université Paris-Sud, CHU de Bicêtre, 94270 Le Kremlin-Bicêtre, France
| | - J-P Girardet
- Université Pierre et Marie Curie-Paris 6, 75005 Paris, France
| | - D Turck
- Université Lille 2, LIRIC-Inserm U995, 59037 Lille, France
| | - A Briend
- Institut de recherche pour le développement, 13572 Marseille, France
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13
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Nutrition Practices and Predictors of Postnatal Growth in Preterm Infants During Hospitalization: A Longitudinal Study. J Pediatr Gastroenterol Nutr 2018; 66:312-317. [PMID: 28953525 DOI: 10.1097/mpg.0000000000001747] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
UNLABELLED Premature infants are at high risk of undernutrition and extrauterine growth restriction. AIM The aim of the study was to evaluate the relation between nutrition practices and growth rate in preterm infants from birth to 36 weeks postmenstrual age (PMA). METHODS Longitudinal data were collected retrospectively in 103 infants born <33 weeks gestation admitted to Dunedin Neonatal Intensive Care Unit, New Zealand. Weight, length, and head circumference at birth and 36 weeks PMA z scores were calculated using the INTERGROWTH Preterm Growth Standard. Growth velocity (g · kg · day) was determined via exponential model. Time to regain birth weight and nutritional practices including enteral nutrition, withholding feeds, nutrient intake, and feeding at discharge were described. Regression was used to explore associations between growth and nutritional variables. RESULTS Growth faltering (weight-for-age z score <-1.28/10th centile) increased from 9% at birth to 19% at 36 weeks PMA. Mean (standard deviation) growth velocity in-hospital (14.2 [3.3] g · kg · day) was well below the desirable rate of 18 g · kg · day. Forty-one percent of infants had feeds withheld, which was significantly associated with a longer time period to achieve full enteral feedings (P < 0.001) and poorer weight and length z score at 36 weeks PMA (both P < 0.05). The day of life to establish full enteral feedings was longer than recommended yet positively associated with weight at 36 weeks PMA (P = 0.019), whereas controlling for withholding feeds and other known confounders. CONCLUSIONS Extrauterine growth restriction was highly prevalent in this population. The negative association of withholding of feeds on growth reinforces the need to evaluate early life feeding protocols and further assess the longer-term influence of this practice on postdischarge growth outcomes.
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14
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Dako J, Buzzard J, Jain M, Pandey R, Groh-Wargo S, Shekhawat P. Slow enteral feeding decreases risk of transfusion associated necrotizing enterocolitis. J Neonatal Perinatal Med 2018; 11:231-239. [PMID: 29843272 DOI: 10.3233/npm-181773] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Necrotizing Enterocolitis (NEC) is a multifactorial condition where PRBC transfusion is associated with necrotizing enterocolitis (TANEC) in about a third of all cases of NEC. We have investigated the role of feeding practices in incidence of TANEC. We sought to compare infants diagnosed with TANEC versus infants diagnosed with classic NEC and investigated the effects of a standardized slow enteral feeding (SSEF) protocol on TANEC incidence as well as the effects of SSEF on growth of infants with NEC. METHODS We conducted a retrospective cohort study, where medical records of infants born in a tertiary care neonatal intensive care unit (level IIIb) from January 1997 to May 2014 with birth weight < 1500 grams and gestational age≤34 weeks with NEC stage IIa or greater according to the modified Bell's staging were reviewed. RESULTS During the study period, 111 infants developed NEC, and 41/111 (37%) were diagnosed with TANEC. Infants with TANEC were smaller, more premature, had higher SNAPPE scores and were more anemic prior to transfusion compared with infants with 'classic NEC'. The severity of NEC did not differ between the two groups, however, infants with TANEC had worse outcomes and longer NICU stays. Introduction of SSEF protocol, led to a significant decrease in TANEC. There was no difference in weight and head circumference of infants in the two groups at 2 years corrected age. CONCLUSION SSEF led to a significant reduction in the incidence of TANEC without impairing growth at 2 years corrected age.
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MESH Headings
- Blood Transfusion/methods
- Enteral Nutrition/methods
- Enterocolitis, Necrotizing/etiology
- Enterocolitis, Necrotizing/physiopathology
- Enterocolitis, Necrotizing/therapy
- Female
- Gestational Age
- Humans
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/physiopathology
- Infant, Premature, Diseases/therapy
- Infant, Very Low Birth Weight
- Male
- Retrospective Studies
- Risk Factors
- Transfusion Reaction
- Treatment Outcome
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Affiliation(s)
- J Dako
- Department of Pediatrics, Division of Neonatology, Metro Health Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - J Buzzard
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - M Jain
- Department of Pediatrics, Division of Neonatology, Metro Health Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - R Pandey
- Department of Pediatrics, Division of Neonatology, University of Texas Health Science Center at Houston, TX, USA
| | - S Groh-Wargo
- Department of Pediatrics, Division of Neonatology, Metro Health Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - P Shekhawat
- Department of Pediatrics, Division of Neonatology, Metro Health Medical Center, Case Western Reserve University, Cleveland, OH, USA
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15
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Westin V, Klevebro S, Domellöf M, Vanpée M, Hallberg B, Stoltz Sjöström E. Improved nutrition for extremely preterm infants - A population based observational study. Clin Nutr ESPEN 2017; 23:245-251. [PMID: 29460807 DOI: 10.1016/j.clnesp.2017.09.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 09/20/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND AND AIMS Extremely preterm (EPT) infants are at high risk for malnutrition due to immaturity and medical complications and they often accumulate nutritional deficits and experience growth faltering during treatment at neonatal intensive care units (NICUs). Enhanced intake of energy and protein during the first weeks of life improves weight gain and head circumference growth. The optimal nutritional strategy for these infants' health and long-term development remains unknown. Nutritional regiments have been identified as a potential area for improvement in Swedish NICUs. The aim of this study was to evaluate changes in nutritional intake over time during the first 56 postnatal days in EPT (<27 gestational weeks; n = 316) infants, who were treated in NICUs during 2004-2011 in Stockholm, using a population-based study approach. METHODS Several different nutritional interventions were implemented over the 8-year period. Nutrition and growth data were obtained retrospectively from hospital records. All intakes of enteral and parenteral nutrients were retrieved daily during the first 28 postnatal days and on days 35, 42, 49 and 56. RESULTS Energy intake (median) increased from 77 kcal/kg/d during the 2004-2005 period to 98 kcal/kg/d during the 2010-2011 period on days 4-6. Median protein intake increased from 2.4 g/kg/d during 2004-2005 to 3.6 g/kg/d during 2010-2011. Energy and protein intake during postnatal days 0-6 increased continuously over the 8 years and protein intake increased during all 56 postnatal days. Full enteral feeds were reached earlier and the proportion of enteral feeds during the first week was higher during 2008-2009 compared to all other years. A significant improvement in growth was primarily noted by comparing the 2004-2005 period to subsequent years. CONCLUSIONS Neonatal nutrition improved significantly in Stockholm from 2004 to 2011. Above all, parenteral nutrition was initiated more promptly during the first week and was provided at higher quantities. However, many of the EPT infants born during the later years still did not reach the recommended macronutrient intake levels. A significant weight gain improvement was observed between 2004-2005 and 2006-2011.
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Affiliation(s)
- Vera Westin
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Function Area Clinical Nutrition, Karolinska University Hospital, Stockholm, Sweden.
| | - Susanna Klevebro
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Sachs' Children and Youth Hospital, South General Hospital, Stockholm, Sweden
| | - Magnus Domellöf
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Mireille Vanpée
- Department of Women and Child Health, Karolinska Institutet, Stockholm, Sweden
| | - Boubou Hallberg
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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16
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Immeli L, Andersson S, Leskinen M, Vuorinen E, Rinta-Koski OP, Luukkainen P. Improved postnatal growth of extremely low-birthweight boys over the last two decades. Acta Paediatr 2017; 106:676-679. [PMID: 28118489 DOI: 10.1111/apa.13752] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 11/22/2016] [Accepted: 01/20/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Lotta Immeli
- Clinical Medicine, Department of Paediatrics, University of Helsinki, Helsinki, Finland
| | - Sture Andersson
- Children's Hospital, University of Helsinki, Helsinki, Finland.,Helsinki University Hospital, Helsinki, Finland
| | - Markus Leskinen
- Children's Hospital, University of Helsinki, Helsinki, Finland.,Helsinki University Hospital, Helsinki, Finland
| | | | | | - Päivi Luukkainen
- Children's Hospital, University of Helsinki, Helsinki, Finland.,Helsinki University Hospital, Helsinki, Finland
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