Early Nutrition and Growth until the Corrected Age of 2 Years in Extremely Preterm Infants

The crosstalk between FGF21 and GH leads to weakened GH receptor signaling and IGF1 expression and is associated with growth failure in very preterm infants

Background

Fibroblast growth factor 21 (FGF21) is an essential metabolic regulator that adapts to changes in nutritional status. Severe childhood undernutrition induces elevated FGF21 levels, contributing to growth hormone (GH) resistance and subsequent linear growth attenuation potentially through a direct action on chondrocytes.

Methods

In this study, we assessed expression of the components of both GH and FGF21 pathways in rare and unique human growth plates obtained from children. Moreover, we investigated the mechanistic interplay of FGF21 on GH receptor (GHR) signaling in a heterologous system.

Results

Chronic FGF21 exposure increased GH-induced GHR turnover and SOCS2 expression, leading to the inhibition of STAT5 phosphorylation and IGF-1 expression. The clinical significance of FGF21 signaling through GH receptors was tested in nutritionally driven growth failure seen in very preterm (VPT) infants right after birth. VPT infants display an immediate linear growth failure after birth followed by growth catch-up. Consistent with the in vitro model data, we show that circulating FGF21 levels were elevated during deflection in linear growth compared to catch-up growth and were inversely correlated with the length velocity and circulating IGF1 levels.

Conclusions

This study further supports a central role of FGF21 in GH resistance and linear growth failure and suggests a direct action on the growth plate.

Relationship between nutrient intakes in the transition phase and postnatal growth of preterm infants: a systematic review

Nutrition practices for preterm infants include phases of parenteral nutrition, gradually interrupted parenteral nutrition (transition phase), and full enteral nutrition. However, nutrition management during the transition phase is frequently overlooked. This review examined the relationship between nutrient intake during the transition phase and preterm infant growth. PubMed, Embase, Web of Science, Cochrane, Chinese National Knowledge Infrastructure Database, Wanfang Database, and Chinese Science and Technique Journals Database were searched for studies examining the relationship between nutrient intake during the transition phase and postnatal growth of preterm infants from each database's earliest inception through February 28, 2022. The quality of the studies was assessed using the Newcastle-Ottawa scale. A total of three studies conducted in the USA, Italy and China met the inclusion criteria. The growth indicators were extrauterine growth restriction (weight < 10th percentile for post-menstrual age) or inadequate weight growth velocity (growth velocity < 15 g/kg/d) at discharge or the end of the transition phase. The transition phase was divided into two periods in two studies: the early period (parenteral energy intake > 50% of total energy intake) and the late period (enteral energy intake > 50% of the total energy intake). The cumulative protein intake in the transition phase was generally lower in preterm infants with extrauterine growth restriction or inadequate weight growth velocity, especially in the early transition phase. The deficiency of energy and protein intake during the transition phase cannot be explicitly determined due to differences in growth indicators and definitions of the transition phase. However, enteral protein intake should be closely monitored in the early transition phase to ensure a better growth rate for preterm infants. To elucidate potential associations, further well-designed research will be required.

Nurse-Driven Interventions for Improving ELBW Neurodevelopmental Outcomes

Survival rates for extremely low-birth-weight (ELBW) infants are improving as neurodevelopmental impairment (NDI) rates stay stable, thereby increasing the overall number of infants with NDI. Although there are many determinants of NDI in this population, nutritional factors are of interest because they are readily modifiable in the clinical setting. Nurses can influence nutritional factors such as improving access to human milk feeding, using growth monitoring, establishing feeding policies, implementing oral care with colostrum, facilitating kangaroo care, and providing lactation education for the mother. All of these measures assist in leading to a decrease in NDI rates among ELBW infants.

Improved Macro- and Micronutrient Supply for Favorable Growth and Metabolomic Profile with Standardized Parenteral Nutrition Solutions for Very Preterm Infants

Very preterm infants are at high risk for suboptimal nutrition in the first weeks of life leading to insufficient weight gain and complications arising from metabolic imbalances such as insufficient bone mineral accretion. We investigated the use of a novel set of standardized parenteral nutrition (PN; MUC PREPARE) solutions regarding improving nutritional intake, accelerating termination of parenteral feeding, and positively affecting growth in comparison to individually prescribed and compounded PN solutions. We studied the effect of MUC PREPARE on macro- and micronutrient intake, metabolism, and growth in 58 very preterm infants and compared results to a historic reference group of 58 very preterm infants matched for clinical characteristics. Infants receiving MUC PREPARE demonstrated improved macro- and micronutrient intake resulting in balanced electrolyte levels and stable metabolomic profiles. Subsequently, improved energy supply was associated with up to 1.5 weeks earlier termination of parenteral feeding, while simultaneously reaching up to 1.9 times higher weight gain at day 28 in extremely immature infants (<27 GA weeks) as well as overall improved growth at 2 years of age for all infants. The use of the new standardized PN solution MUC PREPARE improved nutritional supply and short- and long-term growth and reduced PN duration in very preterm infants and is considered a superior therapeutic strategy.

Randomized Trial of Early Enhanced Parenteral Nutrition and Later Neurodevelopment in Preterm Infants

Retrospective studies indicate that the parenteral provision of calories, proteins, and lipids in the first week of life is associated with improved later neurodevelopment. We aimed to determine whether infants randomized to an enhanced parenteral nutrition protocol had improved developmental outcomes at 4, 12, or 24 months corrected age (CA). In total, 90 preterm infants (<32 weeks gestational age and <1500 g) were randomized to receive enhanced parenteral nutrition (PN) or standard PN during the first week of life. The enhanced group received a higher glucose infusion rate and intralipids. Neurodevelopmental outcomes included pattern-reversal visually evoked potentials (VEP) at 4 months CA (n = 33) and the Bayley Scales of Infant Development (BSID) at 12 (n = 46) and 24 (n = 29) months CA. P100 latency was longer in the intervention group, indicating slower processing speed (145 vs. 178 ms, p = 0.01). This association did not hold in multivariable analysis adjusting for potentially confounding variables. BSID scores were not associated with enhanced PN. Higher enteral energy and protein intake regardless of randomization group were associated with faster processing speed at 4 months CA (p ≤ 0.02 for both). Enhanced early PN was not associated with improved neurodevelopment; however, first-week enteral caloric and protein intake were associated with improved speed of processing.

Association between neonatal malnutrition and bronchopulmonary dysplasia in very low-birth-weight infants: A propensity score-matched analysis

OBJECTIVE

To investigate the relationship between the nutrition status of infants with bronchopulmonary dysplasia (BPD) at the first 4 weeks of life and the likelihood of developing neonatal malnutrition.

METHODS

A total of 1064 infants were divided into a BPD group and a non-BPD group. After propensity score matching, there were 282 infants in each group. Infants were further divided into a neonatal malnutrition （NM） group and a well-nourished （WN） group. Clinical factors, nutrition intake, and growth parameters were collected and analyzed. Multivariate logistic regression model was used to determine the factors associated with neonatal malnutrition.

RESULTS

1. Compared with infants in the non-BPD group, the infants in BPD group had more fluid intake and lower calorie and protein intake after the second week, longer invasive ventilation time, and longer time to total oral feeding and parenteral nutrition (PN), and the difference was more significant in NM infants than in WN infants (P < 0.05). 2. The weight/length, body mass index, triponderal mass index, and weight gain velocity in the BPD group were significantly lower than in the non-BPD group (P < 0.05) and lower in NM infants than in WN ones (P < 0.05). 3. Multivariable system regression analysis showed that invasive ventilation time, lipid intake in week 4, time to reach full feeding, and duration of PN were independent risk factors for NM.

CONCLUSION

Enhancing calorie and macronutrient intake, reducing invasive ventilation, and achieving full gastrointestinal feeding early may be effective measures to avoid malnutrition in infants with BPD.

Preterm nutrition and neurodevelopmental outcomes

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

Improving long-term health outcomes of preterm infants: how to implement the findings of nutritional intervention studies into daily clinical practice

Preterm-born children are at risk for later neurodevelopmental problems and cardiometabolic diseases; early-life growth restriction and suboptimal neonatal nutrition have been recognized as risk factors. Prevention of these long-term sequelae has been the focus of intervention studies. High supplies of protein and energy during the first weeks of life (i.e., energy > 100 kcal kg-1 day-1 and a protein-to-energy ratio > 3 g/100 kcal) were found to improve both early growth and later neurodevelopmental outcome. Discontinuation of this high-energy diet is advised beyond 32-34 weeks postconceptional age to prevent excess fat mass and possible later cardiometabolic diseases. After discharge, nutrition with a higher protein-to-energy ratio (i.e., > 2.5-3.0 g/100 kcal) may improve growth and body composition in the short term.Conclusion: Preterm infants in their first weeks of life require a high-protein high-energy diet, starting shortly after birth. Subsequent adjustments in nutritional composition, aimed at achieving optimal body composition and minimizing the long-term cardiometabolic risks without jeopardizing the developing brain, should be guided by the growth pattern. The long-term impact of this strategy needs to be studied. What is Known: • Preterm infants are at risk for nutritional deficiencies and extrauterine growth restriction. • Extrauterine growth restriction and suboptimal nutrition are risk factors for neurodevelopmental problems and cardiometabolic disease in later life. What is New: • Postnatally, a shorter duration of high-energy nutrition may prevent excess fat mass accretion and its associated cardiometabolic risks and an early switch to a protein-enriched diet should be considered from 32-34 weeks postconceptional age. • In case of formula feeding, re-evaluate the need for the continuation of a protein-enriched diet, based on the infant's growth pattern.

Low caloric intake and high fluid intake during the first week of life are associated with the severity of bronchopulmonary dysplasia in extremely low birth weight infants

OBJECTIVE

To study whether there is an association between nutritional intake during the first week of life and severity of bronchopulmonary dysplasia (BPD) in extremely low birth weight (ELBW) infants.

METHODS

In a retrospective cohort study, medical records of all ELBW infants admitted to our Neonatal Intensive Care Unit (2010-2017) were reviewed for infants' demographics, clinical characteristics, nutritional intake during their first week of life, and BPD risk factors.

RESULTS

During the study period 226 infants were identified of whom 67% (151/226) had moderate-severe BPD and the rest served as controls. Overall infants with moderate-severe BPD were younger, smaller, and spent more time on mechanical ventilation than their controls [(mean±standard deviation) 24.7±1.7 vs. 26.8±2.0 weeks gestational age (p < 0.001); 678±154 vs. 837±129 grams (p < 0.001); and 37.9±23.6 vs. 13.7±15.3 days (p < 0.001) respectively]. During the first week of life, the average caloric, carbohydrate, protein and lipid intakes were significantly lower, and the average fluid intake was significantly higher in the moderate-severe BPD than the control group. After adjustment for confounders, fluid intake, and days on mechanical ventilation were significantly associated with moderate-severe BPD with an odds ratio [OR (95% confidence interval)] of 1.03 (1.01-1.04), and 1.05 (1.03-1.07) respectively. Daily caloric intake was associated with an increased risk for moderate-severe BPD [OR: 0.94 (0.91-0.97)].

CONCLUSION

Low caloric intake, and high fluid intake during the first week of life are associated with the severity of BPD in ELBW infants.

Characteristics and risk factors for extrauterine growth retardation in very-low-birth-weight infants

BACKGROUND

To investigate the characteristics and risk factors for extrauterine growth retardation (EUGR) in very-low-birth-weight infants (VLBWIs).

METHODS

The medical records of 137 VLBWIs admitted to the neonatal intensive care unit between June 2015 and December 2017 were retrospectively reviewed. The patients were divided into EUGR (n = 92) and non-EUGR (n = 45) groups. This study collected data on demographic and clinical characteristics and analyzed the risk factors for EUGR with multivariate logistic regression.

RESULTS

Gestational age (OR = 0.573, P < .01), SGA (OR = 3.887, P = .022), feeding intolerance (OR = 4.632, P = .002), and calories supplied by amino acids at the 7th day (OR = 0.786, P = .006) were high-risk factors for EUGR.

CONCLUSION

Feeding intolerance reduction and amino acid nutrition support should be applied to prevent delayed extrauterine growth for VLBWIs.

Long-term effects on growth of an energy-enhanced parenteral nutrition in preterm newborn: A quasi-experimental study

Aim

To assess the best energy intake in Parenteral Nutrition (PN) for preterm newborns, considering both possible benefits for growth and risk of complications.

Methods

Quasi-experimental study comparing two cohorts of newborns, receiving Energy-Enhanced vs. Standard PN (Cohort A, from 1st January 2015 to 31 January 2016 and Cohort B from 1st February 2016 to 31 March 2017; respectively) after implementation of a change in the PN protocol. The primary outcome measure was growth at 24 months of life. The PN associated complications were also measured.

Results

We enrolled 132 newborns in two Cohorts, similar for prenatal and postnatal clinical characteristics. Although, body weight and length at 24 months of life were significantly higher (p<0.05) in the Cohort A (11.1, 95% CI 10.6 to 11.6 Kg; 85.0 95% CI 83.8 to 86.2 cm) compared with Cohort B (10.4, 95% CI 9.9 to 10.9 Kg; 81.3 95% CI 79.7 to 82.8 cm), body weight and length Z-Score in the first 24 months of life were similar between the two Cohorts. The rate of PN associated complications was very high in both study Cohorts (up to 98% of enrolments). Multivariate analysis showed that length at 24 months was significantly associated with receiving standard PN (cohort A) in the first week of life and on the energy intake in the first week of life. We also found a marginally insignificant association between Cohort A assignment and body weight at 24 months of life (p = 0.060).

Conclusions

Energy-enhanced PN in early life has not significant effects on long-term growth in preterm newborns. The high prevalence of PN associated complications, poses concerns about the utility of high energy intake recommended by current guidelines for PN.

Calorie intake is associated with weight gain during transition phase of nutrition in female extremely low birth weight infants

We sought to determine whether there are sex-based differences in the requirements for calories or protein for optimal growth during the transition phase (TP) when an extremely low birth weight (ELBW) infant, defined as a preterm infant with a birth weight of < 1000 g, is progressing from parenteral to enteral feeds. A retrospective review of ELBW infants born from 2014 to 2016 was performed at a tertiary NICU. Infants with necrotizing enterocolitis, short bowel syndrome, or chromosomal anomalies were excluded. TP was defined as the period when the infant's enteral feeds were increased from 30 up to 120 ml/kg/day while weaning parenteral nutrition (PN). Effects of sex and protein-calorie intake on the change in growth parameters from the beginning to the end of TP were analyzed. Pre-TP growth percentiles and calorie and protein intake were similar in both sexes. There was a significant (r = 0.22, p = 0.026) correlation of total calorie intake with a change in weight percentiles (wt.pc) for the whole group, but on sex-specific analysis, this correlation was more robust and significant only in girls (r = 0.28, p = 0.015). Protein intake did not correlate with the changes in wt.pc in either sex. Despite a similar intake of calories and protein during the TP, we found a significant decrease in wt.pc only in girls. More extensive studies are needed to understand the sex-based differences in caloric needs and metabolic rate in ELBW infants.

Simultaneous exploration of nutrients and pollutants in human milk and their impact on preterm infant growth: An integrative cross-platform approach

Early nutritional management including fortified human breastmilk is currently recommended to fulfil the energy demands and counterbalance risks associated to preterm birth. However, little is known about the potential adverse effects of exposure to persistent organic pollutants (POPs) carried in human milk on preterm infant growth. We conducted a pilot study proving the application of an integrative analytical approach based on mass spectrometry (MS) coupled to advanced statistical models, favouring the comprehensive molecular profiling to support the identification of multiple biomarkers. We applied this workflow in the frame of a preterm infants' cohort to explore environmental determinants of growth. The combination of high resolution gas and liquid chromatography MS platforms generated a large molecular profile, including 102 pollutants and nutrients (targeted analysis) and 784 metabolites (non-targeted analysis). Data analysis consisted in a preliminary examination of associations between the signatures of POPs and the normalised growth of preterm infants, using multivariate linear regression adjusting for known confounding variables. A second analysis aimed to identify multidimensional biomarkers using a multiblock algorithm allowing the integration of multiple datasets in the growth model of preterm infants. The preliminary results did not suggest an impairment of preterm growth associated to the milk concentrations of POPs. The multiblock approach however revealed complex interrelated molecular networks of POPs, lipids, metabolites and amino acids in breastmilk associated to preterm infant growth, supporting the high potential of biomarkers exploration of this proposed workflow. Whereas the present study intended to identify simultaneously pollutant and nutrient exposure profiles associated to early preterm infant growth, this workflow may be easily adapted and applied to other matrices (e.g. serum) and research settings, favouring the functional exploration of environmental determinants of complex and multifactorial diseases.

Prematurity With Extrauterine Growth Restriction Increases the Risk of Higher Levels of Glucose, Low-Grade of Inflammation and Hypertension in Prepubertal Children

Introduction: An adipose tissue programming mechanism could be implicated in the extrauterine growth restriction (EUGR) of very preterm infants with morbidity in the cardiometabolic status later in life, as has been reported in intrauterine growth restriction. The aim of this study was to assess whether children with a history of prematurity and EUGR, but also with an adequate growth, showed alterations in the metabolic and inflammatory status. Methods: This was a case-control study. A total of 88 prepubertal children with prematurity antecedents were selected: 38 with EUGR and 50 with an adequate growth pattern (PREM group). They were compared with 123 healthy children born at term. Anthropometry, metabolic parameters, blood pressure (BP), C-reactive protein, hepatocyte growth factor (HGF), interleukin-6 (IL-6), IL-8, monocyte chemotactic protein type 1 (MCP-1), neural growth factor, tumour necrosis factor-alpha (TNF-α) and plasminogen activator inhibitor type-1 were analysed at the prepubertal age. Results: EUGR children exhibited higher BP levels and a higher prevalence of hypertension (46%) compared with both PREM (10%) and control (2.5%) groups. Moreover, there was a positive relationship between BP levels and values for glucose, insulin and HOMA-IR only in children with a EUGR history. The EUGR group showed higher concentrations of most of the cytokines analysed, markedly higher TNF-α, HGF and MCP-1 levels compared with the other two groups. Conclusion: EUGR status leads to cardiometabolic changes and a low-grade inflammatory status in children with a history of prematurity, and that could be related with cardiovascular risk later in life.

Infant growth, neurodevelopment and gut microbiota during infancy: which nutrients are crucial?

PURPOSE OF REVIEW

To update the role of specific nutrients during infant development.

RECENT FINDINGS

Several bioactive nutrients such as long-chain polyunsaturated fatty acids (LC-PUFAs), iron, vitamins, proteins, or carbohydrates have been identified to exert an important role during the first 1000 days of life on infant growth, neurodevelopment, and gut microbiota establishment and maturation. LC-PUFAs are structural constituents of the central nervous system (CNS), being essential in retinal development or hippocampal plasticity. Recently, components of the milk fat globule membrane (MFG) are being added to infant formulas because of their key role in infant's development. A high intake of proteins induces a faster weight gain during infancy which correlates with later obesity. Digestible carbohydrates provide glucose, crucial for an adequate functioning of CNS; nondigestible carbohydrates [e.g. human milk oligosaccharides (HMOs)] are the main carbon source for gut bacteria. Iron-deficiency anemia during infancy has been associated with alterations of mental and psychomotor development. Folate metabolism, closely related to vitamins B6 and B12, controls epigenetic changes, whereas inadequate status of vitamin D affects bone development, but may also increase intestinal permeability and alter gut microbiota composition.

SUMMARY

LC-PUFAs, proteins, carbohydrates, iron, and vitamins during early life are critical for infant's growth, neurodevelopment, and the establishment and functioning of gut microbiota.

Three-hourly feeding intervals are associated with faster advancement in very preterm infants

OBJECTIVE

To compare the effect of two-hourly (Q2H) vs. three-hourly (Q3H) feeding on time to achieve full enteral feeding, growth metrics and respiratory tolerance in very preterm infants with birth weight ≤ 1250 g.

STUDY DESIGN

Retrospective study review of 18 months before and after a change in our feeding guideline from Q3H to Q2H feedings.

RESULTS

113 infants were included, 59 in Q3H and 54 in Q2H groups. Q2H infants required 10% more days to achieve full enteral feeding, however it was not statistically significant (P = 0.054). Q2H feeding was associated with 16% more central catheter days (P = 0.02) and 17% more parenteral nutrition days (P = 0.019). There were no differences in respiratory outcomes or growth metrics between the groups.

CONCLUSION

Very preterm infants fed Q3H had less central catheter and parenteral nutrition days when compared to those fed Q2H, without significant differences in growth or respiratory outcomes.

Development of a human milk concentrate with human milk lyophilizate for feeding very low birth weight preterm infants: A preclinical experimental study

Breast milk is considered the gold standard nutritional resource for very low birth weight (VLBW) infants in terms of nutrients and protective factors. If mother's milk is not available, the second choice is donated and fortified human milk (HM) from the Human Milk Bank (HMB). This study hypothesized that HM could be lyophilized and used as an additive to increase the levels of macronutrients and micronutrients available to VLBW infants. This study aimed to constitute a lyophilized HM concentrate and determine the osmolality and the concentration of macronutrients and micronutrients in HM samples at “baseline” and in “HM concentrates”, analyzed immediately (HMCI), and after 3 (HMC3m) and 6 (HMC6m) months of freezing. Osmolality was verified using the freezing point osmometric method. Macronutrient quantification was performed using the MIRIS Human Milk Analyzer. Micronutrients were determined by Flame Atomic Absorption Spectrophotometry and by the automated colorimetric method. Bayesian linear mixed effect models were adjusted using OpenBUGS to estimate mean differences and 95% credibility intervals (CrI) of osmolality and of macro- and micronutrients between the types of HM samples. A comparison of dosage values showed a significant increase between HM baseline and HMCI, HMC3m, and HMC6m. Comparing HM baseline and HMCI highlighted the increase in energy content and the concentration of carbohydrates and total lipids. The Ca and P contents increased and the levels of energy, total lipids, and Cu were reduced in HMC3m compared to HMCI. Ca, Mg, K, Zn, and P increased and the levels of energy, total lipids, and Cu were reduced in HMC6m, compared to HMCI. The present study confirms the possibility of formulation and utilization of the immediate concentrate. Partial stability of HM concentrates generated from freeze-drying of donated milk do not recommend storage.