Neonatal morbidities and postnatal growth failure in very low birth weight, very preterm infants

Early postnatal growth failure in infants <1500 g in a Ugandan referral hospital: a retrospective cohort study

BACKGROUND

Postnatal growth failure (PGF), a multifactorial condition is common in preterm infants and infants born weighing <1500 g and is associated with impaired neurodevelopmental and growth outcomes. In low-resource settings, like Uganda, parenteral nutrition and breastmilk fortifier are often unavailable, and preterm infants rely solely on their mother's expressed breastmilk, which can be inadequate. This retrospective cohort study, conducted in a level II neonatal unit in eastern Uganda, aimed to evaluate the incidence of and risk factors for postnatal growth failure among infants <1500 g.

METHODS

The study included infants with birthweight <1500 g, admitted within 24 h of birth, and who spent 7 or more days in the neonatal unit. Major congenital malformations or a diagnosis of hypoxic ischemic encephalopathy were exclusion criteria. PGF was defined as a decrease in weight Z score between birth and discharge of more than - 1.28. Data on feeding, anthropometry, co-morbidities, and clinical measures were extracted from medical records. Statistical analyses were performed using Stata 17.0 with crude and adjusted relative risks (RR) were reported.

RESULTS

One hundred and four infants were recruited, including 47 (45.2%) male and 57 (54.8%) female, with a mean birth weight of 1182 g (SD 18 g, 95% CI: 1140, 1210). Almost half were small for gestational age, most were singletons (66.3%), and most were born by spontaneous vaginal delivery (82.7%). PGF was observed at discharge in 75.9% (N = 79). Clinical risk factors for PGF included: small for gestational age (cRR 1.25, 95% CI: 1.01, 1.53), respiratory distress syndrome (aRR 1.30 95% CI: 1.01, 1.67), duration of bubble continuous positive airway pressure use (aRR 1.35, 95% CI: 1.10, 1.66), sepsis requiring second line (aRR 1.58, 95% CI: 1.22, 2.04) and third line treatment (aRR 1.46, 95% CI: 1.20, 1.77), prolonged time to achieve full feeds (aRR 1.30, 95% CI: 1.01, 1.66) and prolonged hospitalisation (aRR 1.85, 95% CI: 1.31, 2.61).

CONCLUSION

PGF was common among infants <1500 g in this hospitalised cohort who were primarily fed on their mother's own milk. Urgent action is needed to enhance postnatal growth in this vulnerable patient group. Future research should focus on exploring multidisciplinary interventions that can improve growth outcomes in this population and understanding the long-term implications and need for care for these infants.

Early human milk feeding: Relationship to intestinal barrier maturation and postnatal growth

OBJECTIVES

Early exposure to mother's own milk (MOM) promotes intestinal barrier maturation in preterm infants. We hypothesized (1) donor human milk (DHM) supplementation reduces intestinal permeability (IP) similar to exclusive MOM and (2) early HM exposure and low IP at 7-10 days postnatal age (PNA) are associated with improved growth outcomes.

METHODS

IP was measured by the standard sugar absorption test (SAT) in infants <33 weeks gestation between 7-10 days PNA. Nutritional and anthropometric data were recorded. Postnatal growth failure (PNGF) was defined as a decrease in weight z-score >1 from birth to discharge to home.

RESULTS

Of 158 preterm infants, the mean (SD) gestational age was 29.9(2.3) weeks and birthweight 1388(424) g. Diet prior to SAT was exclusive MOM [N = 55(35%)], DHM ± MOM [N = 52(33%)], or preterm formula±MOM [N = 51(32%)]. The mean Lactulose(La)/Rhamnose(Rh) ratio was lower in the exclusive MOM [0.06(0.07)] and DBM ± MOM [0.05(0.07)] groups compared to the preterm formula±MOM group [0.11(0.11)], p < 0.01). Cumulative intake >150 ml/kg MOM ± DHM, but not preterm formula within 7-10 days PNA was associated with early intestinal barrier maturation. Low IP was not associated with lower risk of PNGF at discharge.

CONCLUSIONS

Low IP is associated with cumulative intake of MOM alone or supplemented with DHM > 150 ml/kg within 7-10 days PNA.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov NCT01756040 ; web link to study on registry: https://clinicaltrials.gov/study/NCT01756040 .

IMPACT

Key message Early intestinal barrier maturation is associated with cumulative intake of exclusive MOM alone or supplemented with DHM > 150 ml/kg within 7-10 days after birth, but is not associated with lower risk of PNGF at time of discharge. What it adds to existing literature? This observational study is the first study to demonstrate that supplemental DHM promotes intestinal barrier maturation similar to MOM alone. What is the impact? The findings underscore the importance of early introduction of human milk feeds as MOM or MOM supplemented with DHM in sufficient volume to promote early intestinal barrier maturation.

Neonatal nutrition and early childhood body composition in infants born extremely preterm

BACKGROUND & AIMS

Previous studies have observed changes in fat and fat-free mass among preterm infants when compared to term-born infants. However, these studies have mainly focused on moderate or very preterm infants, with a scope limited to the first few years of life. We aimed to compare body composition in extremely preterm infants to term-born infants in early childhood. Additionally, we investigated whether early neonatal nutrition was associated with the distribution of fat- and fat-free mass in later life.

METHODS

The study used dual-energy x-ray absorptiometry to evaluate the body composition of 52 children aged 6-9-years, of whom 35 were born extremely preterm and 17 were born at term and was analyzed using multivariate linear regression. Nutritional intakes of fluids, energy, and macronutrients during the first eight postnatal weeks for 26 extremely preterm infants were investigated in relation to body composition at age 6-9 years using Bayesian regression analysis and Gradient Boosting Machine.

RESULTS

Children born extremely preterm had smaller head circumference (confidence interval -8.7 to -1.7), shorter height (confidence interval -2.7 to -0.6), higher waist to height ratio (confidence interval 0.01-0.05) and lower fat-free mass (confidence interval -3.9 to -0.49), compared to children born at full-term. Children born extremely preterm had a differing response to amount of fluid and macronutrient intake for both fat mass index and fat-free mass index. A bimodal response showed high intake of fluid and macronutrients as associated with high fat mass index for some children, whereas others demonstrated an inverse association, suggesting analysis on cohort-level as problematic.

CONCLUSIONS

Childhood body composition differs between extremely preterm infants and term-born infants. Extremely preterm infants display differing responses in their body composition to varying levels of fluids and macronutrient intake during the neonatal period.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Nutrition of the preterm infant with persistent ductus arteriosus: existing evidence and practical implications

The persistence of a patent ductus arteriosus (PDA) is a common condition in preterm infants with a prevalence inversely proportional to gestational age. PDA is associated with mild-to-severe gastrointestinal complications such as feeding intolerance, gastrointestinal perforation, and necrotizing enterocolitis, which represent a major challenge for the nutritional management in preterm infants. In this context, the Section on Nutrition, Gastroenterology and Metabolism and the Circulation Section of the European Society for Pediatric Research have joined forces to review the current knowledge on nutritional issues related to PDA in preterm infants. The aim of the narrative review is to discuss the clinical implications for nutritional practice. Because there is little literature on postnatal nutrition and PDA in preterm infants, further research with well-designed studies on this topic is urgently needed. Guidelines should also be developed to clearly define the implementation and course of enteral nutrition and the target nutritional intake before, during, and after pharmacologic or surgical treatment of PDA, when indicated. IMPACT: Persistent ductus arteriosus (PDA) is associated with gastrointestinal complications such as feeding intolerance, gastrointestinal perforation, and necrotizing enterocolitis, which pose a major challenge to the nutritional management of preterm infants. In PDA infants, fluid restriction may lead to inadequate nutrient intake, which may negatively affect postnatal growth and long-term health. The presence of PDA does not appear to significantly affect mesenteric blood flow and splanchnic oxygenation after enteral feedings. Initiation or maintenance of enteral nutrition can be recommended in infants with PDA.

A Global Perspective on PDA Management in the Extremely Premature: Shifting Trend Toward Transcatheter Closure

Patent ductus arteriosus (PDA) is a frequently encountered defect in infants born extremely premature (≤26 weeks' gestation). Historically, closure of the PDA was performed using cyclooxygenase inhibitor medications or by surgical ligations. However, the benefits of PDA closure using these therapies have never been demonstrated, albeit studies have previously not focused on the extremely premature infants. Therefore, there was a worldwide trend toward conservative management of the PDA. With improved survival of extremely premature infants, comorbidities associated with the PDA has increased, resulting in finding alternate treatments such as transcatheter patent ductus arteriosus closure (TCPC) for this population. Currently, there is a renewed interest toward selective treatment of the PDA in this high-risk cohort of small infants. This Comprehensive Review article inspects the globally changing trends in the management of the PDA in premature infants, with a special focus on the rising adoption of TCPC. Moreover, this article compiles data from several neonatal networks worldwide to help understand the problem at hand. Understanding the current management of premature infants and their outcomes is fundamentally essential if pediatric cardiologists are to offer TCPC as a viable therapeutic option for this population. This article aims to serve as a guide for pediatric cardiologists on this topic by compiling the results on landmark clinical trials on PDA management and the controversies that arise from these trials. Comparative outcomes from several countries are presented, including interpretations and opinions of the data from experts globally. This is a step toward coming to a global consensus in PDA management in premature infants.

Growth and differentiation factor 15 (GDF15) levels predict adverse respiratory outcomes in premature neonates

Growth and differentiation factor 15 (GDF15) is a stress-responsive cytokine, and its expression increases during inflammation, hyperoxia, and senescence. Significantly, GDF15 is secreted by the placenta, and maternal levels increase throughout pregnancy. Serum GDF15 level is a promising biomarker for many lung diseases like pulmonary hypertension and pulmonary fibrosis. However, circulating GDF15 levels in preterm infants and their role as a predictor of respiratory outcomes have not been studied. We hypothesized that GDF15 levels would increase with gestational age at birth, and that postnatal GDF15 will be correlated with adverse respiratory outcomes in preterm infants. Scavenged blood samples were retrieved from 57 preterm infants at five time points, from birth until 36-weeks postmenstrual age (PMA). GDF15 levels were measured using ELISA in 114 samples. We performed two-sample t-test, correlation and linear regression, logistic regression, and mixed-effects linear models for statistical analysis, and significance was identified when p < 0.05. Contrary to our hypothesis, for every 1-week increase in gestational age at birth, the predicted GDF15 level decreased by 475.0 pg/ml (p < 0.001). Greater PMA was significantly associated with lower serum GDF15 levels (p < 0.001). Interestingly, higher GDF15 levels were associated with a longer need for mechanical ventilation (p = 0.034), prolonged respiratory support need (p < 0.001), and length of hospital stay (p = 0.006). In conclusion, in preterm infants, GDF15 levels show an inverse correlation with gestational age at birth, with higher levels in more preterm babies, and levels trend down postnatally. Furthermore, longitudinal GDF15 levels through 36 weeks PMA predict adverse respiratory outcomes in preterm infants.