Update on Nutrition for Preterm and Full-Term Infants

Low-cost and open-source neonatal incubator operated by an Arduino microcontroller

An unacceptably large number of newborn infants die in developing countries. For a considerable number of cases (particularly in preterm infants), morbidity and mortality can be reduced by simply maintaining newborn thermal homeostasis during the first weeks of life. Unfortunately, deaths caused by prematurity remain inordinately common in low- and middle-income countries (LMICs) due to reduced access to incubators in light of the high cost of commercially available devices. We herein describe and test a low-cost and easy-to-assemble neonatal incubator created with inexpensive materials readily available in LMICs. The incubator is based on an Arduino microcontroller. It maintains controlled temperature and relative humidity inside the main chamber while continuously measuring newborn weight progress. Moreover, the incubator has a tilting bed system and an additional independent safety temperature alarm. The performance of the novel low-cost neonatal incubator was evaluated and successfully passed the IEC 60601-2-19 standards. In the present work, we provide all the necessary technical information, which is distributed as open source. This will enable assembly of very low-cost (<250 €) and fully functional incubators in LMICs that should help reduce neonatal mortality.

Effects of mixed oil emulsion on short-term clinical outcomes in premature infants: A prospective, multicenter, randomized controlled trial

OBJECTIVE

This study compared the clinical effects of two different lipid emulsions in premature infants with gestational age < 32 weeks (VPI) or birth weight < 1500 g (VLBWI) to provide an evidence-based medicine basis for optimizing intravenous lipid emulsion.

METHODS

This was a prospective multicenter randomized controlled study. A total of 465 VPIs or VLBWIs, admitted to the neonatal intensive care unit of five tertiary hospitals in China from March 1, 2021 to December 31, 2021, were recruited. All subjects were randomly allocated into two groups, namely, medium-chain triglycerides/long-chain triglycerides (MCT/LCT) group (n = 231) and soybean oil, medium-chain triglycerides, olive oil, and fish oil (SMOF) group (n = 234). Clinical features, biochemical indexes, nutrition support therapy, and complications were analyzed and compared between the two groups.

RESULTS

No significant differences were found in perinatal data, hospitalization, parenteral and enteral nutrition support between the two groups (P > 0.05). Compared with the MCT/LCT group, the incidence of neonates with a peak value of total bilirubin (TB) > 5 mg/dL (84/231 [36.4% vs. 60/234 [25.6%]), a peak value of direct bilirubin (DB) ≥ 2 mg/dL (26/231 [11.3% vs. 14/234 [6.0%]), a peak value of alkaline phosphatase (ALP) > 900 IU/L (17/231 [7.4% vs. 7/234 [3.0%]), and a peak value of triglycerides (TG) > 3.4 mmol/L (13/231 [5.6% vs. 4/234[1.7%]]) were lower in the SMOF group (P < 0.05). Univariate analysis showed that in the subgroup analysis of < 28 weeks, the incidence of parenteral nutrition-associated cholestasis (PNAC) and metabolic bone disease of prematurity (MBDP) were lower in the SMOF group (P = 0.043 and 0.029, respectively), whereas no significant differences were present in the incidence of PNAC and MBDP between the two groups at > 28 weeks group (P = 0.177 and 0.991, respectively). Multivariate logistic regression analysis revealed that the incidence of PNAC (aRR: 0.38, 95% confidence interval [CI]: 0.20-0.70, P = 0.002) and MBDP (aRR: 0.12, 95% CI: 0.19-0.81, P = 0.029) in the SMOF group were lower than that in the MCT/LCT group. In addition, no significant differences were recorded in the incidence of patent ductus arteriosus, feeding intolerance, necrotizing enterocolitis (Bell's stage ≥ 2), late-onset sepsis, bronchopulmonary dysplasia, intraventricular hemorrhage, periventricular leukomalacia, retinopathy of prematurity and extrauterine growth retardation between the two groups (P > 0.05).

CONCLUSIONS

The application of mixed oil emulsion in VPI or VLBWI can reduce the risk of plasma TB > 5 mg/dL, DB ≥ 2 mg/dL, ALP > 900 IU/L, and TG > 3.4 mmol/L during hospitalization. SMOF has better lipid tolerance, reduces the incidence of PNAC and MBDP, and exerts more benefits in preterm infants with gestational age < 28 weeks.

MUC-FIRE: Study protocol for a randomized multicenter open-label controlled trial to show that MUCous FIstula REfeeding reduces the time from enterostomy closure to full enteral feeds

Background

After enterostomy creation, the distal bowel to the ostomy is excluded from the physiologic passage of stool, nutrient uptake, and growth of this intestinal section. Those infants frequently require long-term parenteral nutrition, continued after enterostomy reversal due to the notable diameter discrepancy of the proximal and distal bowel. Previous studies have shown that mucous fistula refeeding (MFR) results in faster weight gain in infants. The aim of the randomized multicenter open-label controlled MUCous FIstula REfeeding ("MUC-FIRE") trial is to demonstrate that MFR between enterostomy creation and reversal reduces the time to full enteral feeds after enterostomy closure compared to controls, resulting in shorter hospital stay and less adverse effects of parenteral nutrition. Methods/Design: A total of 120 infants will be included in the MUC-FIRE trial. Following enterostomy creation, infants will be randomized to either an intervention or a non-intervention group.In the intervention group, perioperative MFR between enterostomy creation and reversal will be performed. The control group receives standard care without MFR.The primary efficacy endpoint of the study is the time to full enteral feeds. Secondary endpoints include first postoperative bowel movement after stoma reversal, postoperative weight gain, and days of postoperative parenteral nutrition. In addition adverse events will be analyzed.

Discussion

The MUC-FIRE trial will be the first prospective randomized trial to investigate the benefits and disadvantages of MFR in infants. The results of the trial are expected to provide an evidence-based foundation for guidelines in pediatric surgical centers worldwide.

Trial registration

The trial has been registered at clinicaltrials.gov (number: NCT03469609, date of registration: March 19, 2018; last update: January 20, 2023, https://clinicaltrials.gov/ct2/show/NCT03469609?term=NCT03469609&draw=2&rank=1).

Source of human milk (mother or donor) is more important than fortifier type (human or bovine) in shaping the preterm infant microbiome

Milk fortifiers help meet the nutritional needs of preterm infants receiving their mother's own milk (MOM) or donor human milk. We conducted a randomized clinical trial (NCT03214822) in 30 very low birth weight premature neonates comparing bovine-derived human milk fortifier (BHMF) versus human-derived fortifier (H2MF). We found that fortifier type does not affect the overall microbiome, although H2MF infants were less often colonized by an unclassified member of Clostridiales Family XI. Secondary analyses show that MOM intake is strongly associated with weight gain and microbiota composition, including Bifidobacterium, Veillonella, and Propionibacterium enrichment. Finally, we show that while oxidative stress (urinary F2-isoprostanes) is not affected by fortifier type or MOM intake, fecal calprotectin is higher in H2MF infants and lower in those consuming more MOM. Overall, the source of human milk (mother versus donor) appears more important than the type of milk fortifier (human versus bovine) in shaping preterm infant gut microbiota.

Body Weight Gain Status during the Incubator Weaning Process in Very Low Birth Weight Premature Infants

Incubator care is essential for premature infants during early hospitalization. As the infants’ conditions improve, incubator weaning becomes necessary. This retrospective study aimed to evaluate the effect of body weight gain and status of intake-calorie gain on the incubator weaning process for very low birth weight (VLBW) premature infants. The study included 127 VLBW premature neonates. We analyzed data on clinical characteristics potentially associated with the weaning period and the end-weaning body weight (EWBW), including body weight gain status, intake-calorie gain status, and disease conditions. The neonates were weaned from the incubators at a mean postmenstrual age (PMA) of 35.1 ± 1.3 weeks; postnatal days, 37.7 ± 18.2 days; and body weight, 1882.8 ± 157.1 g. The total weaning period was 3.5 ± 3.1 days. Regarding the weaning period, there was a strong positive relationship only in the end-weaning PMA and the daily body weight within 3 days before incubator weaning. Further, regarding the factors associated with EWBW, only the end-weaning PMA and necrotizing enterocolitis had a significant positive impact. Body weight gain and the status of intake-calorie gain showed no association with either the weaning period or the EWBW and, thus, were not related to the incubator weaning process.

An Evaluation to Establish the Acceptable Serum Triglyceride Levels in Neonates Receiving Intravenous Fat Emulsion Infusion in a Multicenter Retrospective Study

OBJECTIVE

This study aimed to establish neonatal serum triglyceride (TG) level reference ranges during lipid infusion and correlate peak TG with neonatal outcomes.

STUDY DESIGN

This is a retrospective review of 356 neonates with 696 TG measures obtained in four neonatal intensive care units between 2015 and 2017. TG was evaluated collectively to establish a reference range and a threshold limit. To analyze the effects of a higher TG threshold, neonates were categorized by their peak TG: <180 (TG<180), 180 to 400 (TG180-400), and > 400 mg/dL (TG>400). Univariable and multivariable regression models were constructed to compare peak TG to patient characteristic and clinical outcomes.

RESULTS

The frequency of TG > 400 mg/dL was 5% and found only in neonates weighing < 1.5 kg. Neonates in the TG180-400 (n = 91) group were significantly lower in birth weight and gestational age, had lower 5-minute APGAR scores, and had increased ventilatory requirement when compared with neonates in the TG<180 (n = 240) group (all p < 0.001). The TG180-400 group had increased risk of severe intraventricular hemorrhage (p = 0.02) and bronchopulmonary dysplasia (p = 0.03). Elevated TG was associated with mortality (odds ratio [OR]: 14.4, p < 0.001) in univariable analysis, but the relationship weakened (OR: 4.4, p = 0.05) after adjusting for comorbidities in multivariable logistic regression.

CONCLUSION

It is unclear if the adverse outcomes seen in neonates with higher peak TG were due to elevated TG alone, or whether illness severity predicted the increased TG. More prospective studies are needed to further delineate the relationships.

Chrononutrition and Breast Milk: A Review of Circadian Variation in Breast Milk Nutrient Composition

Objective

The objective of this literature review was to identify and summarize the current knowledge on the circadian variation of breast milk nutrients and the implications of these findings.

Method

A review of literature was conducted, including all relevant studies regardless of location and year of publication.

Results

The amino acids tyrosine, histidine, aspartic acid and phenylalanine and energy were observed to be higher during the day. Fat and the vitamins B-1, B-2, B-3, B-6, and B-12 were higher at night. Other studies have shown conflicting results or no circadian variation for certain nutrients. Poor reproducibility and small sample sizes affect the quality of existing research.

Conclusion

More research is needed, and longitudinal studies would help assess the effect of breast milk chrononutrition on the long-term health outcomes of infants.

Longitudinal Study Depicting Differences in Complementary Feeding and Anthropometric Parameters in Late Preterm Infants up to 2 Years of Age

Ensuring the nutritional demands of preterm (PT) infants during complementary feeding could contribute significantly to the infants’ long-term health and development. However, the dietary guidelines for complementary feeding in PT are scarce. Thus, describing dietary intake and identifying nutritional targets for these infants could be of great interest. The aim of this study is to assess the food intake and anthropometric parameters in a Mediterranean infant cohort from 6 to 24 months and to identify nutritional targets especially focused on late preterm infants. This is a longitudinal prospective study analyzing information from administered questionnaires about general characteristics and food frequency consumption in 115 infants (20 PT (32 to 36 gestational weeks), 95 full-term (FT)) at 6, 12 and 24 months of age. Results show that the differences in the prevalence of underweight observed in PT infants vs. FT infants are maintained for up to 6 months of age but disappear at 12 and 24 months. The age of inclusion of new foods and the average intake of the main food groups was not different from that of FTs. Although protein intake at 6 months was directly correlated with weight gain and growth in FT, these associations were not observed in PT. At the nutritional level, the low intake of vitamin D in preterm infants is noteworthy. These findings may be useful when designing new intervention strategies for this population group.

Validity of Random Triglyceride Levels in Infants Receiving Parenteral Nutrition

Background: Intravenous lipid emulsions (IL) are an important part of parenteral nutrition (PN) to meet essential fatty acid (EFA) requirements and metabolic demands of neonates and preterm infants. Some critically-ill neonates may not metabolize IL effectively which can lead to hypertriglyceridemia. Risks associated with this include increased pulmonary vascular resistance, displaced bilirubins, and platelet or macrophage dysfunction. Serum triglyceride (TG) concentration is used as a marker for lipid tolerance and predictor of potential complications involved with IL administration, but the clinical significance of this is still debated. Management of TG levels with regard to timing of laboratory tests, the ideal goal range, and duration of infusion of IL varies across institutions and is not standardized. Methods: Single-center, retrospective study of newborn infants receiving parenteral nutrition (PN). Fasting and non-fasting TG levels were drawn during the same lipid infusion of 2-3g/kg/day. The primary outcome was the difference between fasting and non-fasting TG levels. Statistical assessment of continuous data was done with student t-test and nominal data was evaluated using X2-test and logistic regression. Results: Forty infants were included with mean gestational age at birth of 29.5 ± 3.4 weeks and mean birth weight of 1.3 ± 0.5 kg. Mean time between lab draws while on same IL dose was 11.6 ± 0.2 h with resulting mean fasting and non-fasting (random) TG levels 82 ± 40 mg/dL (95% CI 68.4, 97.6) and 101 ± 40 mg/dL (95% CI 88.5, 115.8), respectively. Mean difference between TG levels during lipid-free interval and during infusion was -18.6 ± 51.2 mg/dL (95% CI -35.0, -2.3; p = 0.03). Conclusion: We concluded there is no difference in the management of IL, when TG level was drawn randomly or as fasting sample. Obtaining TG level during routine lab draws is appropriate. We extrapolated that the administration of IL over 24 h will not interfere with TG level.

Carbohydrate supplementation of human milk to promote growth in preterm infants

BACKGROUND

Preterm infants are born with low glycogen stores and require higher glucose intake to match fetal accretion rates. In spite of the myriad benefits of breast milk for preterm infants, it may not adequately meet the needs of these rapidly growing infants. Supplementing human milk with carbohydrates may help. However, there is a paucity of data on assessment of benefits or harms of carbohydrate supplementation of human milk to promote growth in preterm infants. This is a 2020 update of a Cochrane Review first published in 1999.

OBJECTIVES

To determine whether human milk supplemented with carbohydrate compared with unsupplemented human milk fed to preterm infants improves growth, body composition, and cardio-metabolic and neurodevelopmental outcomes without significant adverse effects.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search Cochrane Central Register of Controlled Trials (CENTRAL 2019, Issue 8) in the Cochrane Library and MEDLINE via PubMed on 22 August 2019. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Published and unpublished controlled trials were eligible if they used random or quasi-random methods to allocate preterm infants in hospital fed human milk to supplementation or no supplementation with additional carbohydrate.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed trial quality and the quality of evidence at the outcome level using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method. We planned to perform meta-analyses using risk ratios (RRs) for dichotomous data and mean differences (MDs) for continuous data, with their respective 95% confidence intervals (CIs). We planned to use a fixed-effect model and to explore potential causes of heterogeneity via sensitivity analyses. We contacted study authors for additional information.

MAIN RESULTS

One unblinded, quasi-randomised controlled trial (RCT) assessing effects of carbohydrate supplementation of human milk in the form of a prebiotic in 75 preterm infants was eligible for inclusion in this review. We identified two publications of the same trial, which reported different methods regarding blinding and randomisation. Study authors confirmed that these publications pertain to the same trial, but they have not yet clarified which method is correct. We were unable to reproduce analyses from the data presented. At 30 days of age, the mean weight of preterm infants in the trial was greater in the prebiotic carbohydrate-supplemented group than in the unsupplemented group (MD 160.4 grams, 95% CI 12.4 to 308.4 grams; one RCT, N = 75; very low-quality evidence). We found no evidence of a clear difference in risk of feeding intolerance (RR 0.64, 95% CI 0.36 to 1.15; one RCT, N = 75 infants; very low-quality evidence) or necrotising enterocolitis (NEC) (RR 0.2, 95% CI 0.02 to 1.3; one RCT, N = 75 infants; very low-quality evidence) between the prebiotic-supplemented group and the unsupplemented group. Duration of hospital stay was shorter in the prebiotic group than in the control group at a median (range) of 16 (9 to 45) days (95% CI 15.34 to 24.09) and 25 (11 to 80) days (95% CI 25.52 to 34.39), respectively. No other data were available for assessing effects of carbohydrate supplementation on short- and long-term growth, body mass index, body composition, and neurodevelopmental or cardio-metabolic outcomes.

AUTHORS' CONCLUSIONS

We found insufficient evidence on the short- and long-term effects of carbohydrate supplementation of human milk in preterm infants. The only trial included in this review presented very low-quality evidence, and study authors provided uncertain information about study methods and analysis. The evidence may be limited in its applicability because researchers included a small sample of preterm infants from a single centre. However, the outcomes assessed are common to all preterm infants, and this trial demonstrates the feasibility of prebiotic carbohydrate supplementation in upper-middle-income countries. Future trials should assess the safety and efficacy of different types and concentrations of carbohydrate supplementation for preterm infants fed human milk. Although prebiotic carbohydrate supplementation in preterm infants is currently a topic of active research, we do not envisage that further trials of digestible carbohydrates will be conducted, as this is currently done as a component of multi-nutrient human milk fortification. Hence we do not plan to publish any further updates of this review.

Carbohydrate supplementation of human milk to promote growth in preterm infants

BACKGROUND

Preterm infants are born with low glycogen stores and require higher glucose intake to match fetal accretion rates. In spite of the myriad benefits of breast milk for preterm infants, it may not adequately meet the needs of these rapidly growing infants. Supplementing human milk with carbohydrates may help. However, there is a paucity of data on assessment of benefits or harms of carbohydrate supplementation of human milk to promote growth in preterm infants. This is a 2018 update of a Cochrane Review first published in 1999.

OBJECTIVES

To determine whether human milk supplemented with carbohydrate compared with unsupplemented human milk fed to preterm infants improves growth, body composition, and cardio-metabolic and neurodevelopmental outcomes without significant adverse effects.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 8), MEDLINE via PubMed (1966 to 21 February 2018), Embase (1980 to 21 February 2018), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 21 February 2018). We also searched clinical trials databases, conference proceedings, and reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-randomised trials.

SELECTION CRITERIA

Published and unpublished controlled trials were eligible if they used random or quasi-random methods to allocate preterm infants in hospital fed human milk to supplementation or no supplementation with additional carbohydrate.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed trial quality and the quality of evidence at the outcome level using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method. We planned to perform meta-analyses using risk ratios (RRs) for dichotomous data and mean differences (MDs) for continuous data, with their respective 95% confidence intervals (CIs). We planned to use a fixed-effect model and to explore potential causes of heterogeneity via sensitivity analyses. We contacted study authors for additional information.

MAIN RESULTS

One unblinded, quasi-randomised controlled trial (RCT) assessing effects of carbohydrate supplementation of human milk in the form of a prebiotic in 75 preterm infants was eligible for inclusion in this review. We identified two publications of the same trial, which reported different methods regarding blinding and randomisation. Study authors confirmed that these publications pertain to the same trial, but they have not yet clarified which method is correct. We were unable to reproduce analyses from the data presented. At 30 days of age, the mean weight of preterm infants in the trial was greater in the prebiotic carbohydrate-supplemented group than in the unsupplemented group (MD 160.4 grams, 95% CI 12.4 to 308.4 grams; one RCT, N = 75; very low-quality evidence). We found no evidence of a clear difference in risk of feeding intolerance (RR 0.64, 95% CI 0.36 to 1.15; one RCT, N = 75 infants; very low-quality evidence) or necrotising enterocolitis (NEC) (RR 0.2, 95% CI 0.02 to 1.3; one RCT, N = 75 infants; very low-quality evidence) between the prebiotic-supplemented group and the unsupplemented group. Duration of hospital stay was shorter in the prebiotic group than in the control group at a median (range) of 16 (9 to 45) days (95% CI 15.34 to 24.09) and 25 (11 to 80) days (95% CI 25.52 to 34.39), respectively. No other data were available for assessing effects of carbohydrate supplementation on short- and long-term growth, body mass index, body composition, and neurodevelopmental or cardio-metabolic outcomes.

AUTHORS' CONCLUSIONS

We found insufficient evidence on the short- and long-term effects of carbohydrate supplementation of human milk in preterm infants. The only trial included in this review presented very low-quality evidence, and study authors provided uncertain information about study methods and analysis. The evidence may be limited in its applicability because researchers included a small sample of preterm infants from a single centre. However, the outcomes assessed are common to all preterm infants, and this trial demonstrates the feasibility of prebiotic carbohydrate supplementation in upper-middle-income countries. Future trials should assess the safety and efficacy of different types and concentrations of carbohydrate supplementation for preterm infants fed human milk. Although prebiotic carbohydrate supplementation in preterm infants is currently a topic of active research, we do not envisage that further trials of digestible carbohydrates will be conducted, as this is currently done as a component of multi-nutrient human milk fortification. Hence we do not plan to publish any further updates of this review.

Impact of endotracheal tube shortening on work of breathing in neonatal and pediatric in vitro lung models

BACKGROUND

Work of breathing accounts for a significant proportion of total oxygen consumption in neonates and infants. Endotracheal tube inner diameter and length significantly affect airflow resistance and thus work of breathing. While endotracheal tube shortening reduces endotracheal tube resistance, the impact on work of breathing in mechanically ventilated neonates and infants remains unknown.

AIM

The objective of this in vitro study was to quantify the effect of endotracheal tube shortening on work of breathing in simulated pediatric lung settings. We hypothesized that endotracheal tube shortening significantly reduces work of breathing.

METHODS

We used the Active-Servo-Lung 5000 to simulate different clinical scenarios in mechanically ventilated infants and neonates under spontaneous breathing with and without pressure support. Endotracheal tube size, lung resistance, and compliance, as well as respiratory settings such as respiratory rate and tidal volume were weight and age adapted for each lung model. Work of breathing was measured before and after maximal endotracheal tube shortening and the reduction of the daily energy demand calculated.

RESULTS

Tube shortening with and without pressure support decreased work of breathing to a maximum of 10.1% and 8.1%, respectively. As a result, the calculated reduction of total daily energy demand by endotracheal tube shortening was between 0.002% and 0.02%.

CONCLUSION

In this in vitro lung model, endotracheal tube shortening had minimal effects on work of breathing. Moreover, the calculated percentage reduction of the total daily energy demand after endotracheal tube shortening was minimal.

Fluid restriction for treatment of preterm infants with chronic lung disease

BACKGROUND

Fluid restriction is often recommended as part of the management of infants with early or established bronchopulmonary dysplasia (BPD).

OBJECTIVES

To determine whether fluid restriction as part of the therapeutic intervention for early or established BPD improves clinical outcomes.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 1) in the Cochrane Library (searched 16 February 2016), MEDLINE via PubMed (1966 to 16 February 2016), Embase (1980 to 16 February 2016), and CINAHL (1982 to 16 February 2016). We also searched clinical trials' databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Prospective randomised clinical trials comparing two distinct fluid administration volumes in preterm infants with early or established BPD.

DATA COLLECTION AND ANALYSIS

We used the standard methods of Cochrane Neonatal. For the included trial, we extracted data and assessed the risk of bias, and used GRADE methods to assess the quality of the evidence. The outcomes considered in this review are effects on mortality or requirement for oxygen at 36 weeks' postmenstrual age (primary outcome measure), the duration of supplemental oxygen therapy, proportion of infants discharged from hospital on oxygen, duration of assisted ventilation, duration of hospitalisation, weight gain, feeding tolerance, apnoea, necrotizing enterocolitis, renal dysfunction or nephrocalcinosis, lung mechanics, and use of diuretic therapy (secondary outcome measures).

MAIN RESULTS

One trial was found, including 60 preterm infants at 28 days of age with persistent oxygen requirements. Infants were randomised to either 180 mL/kg/day of standard formula or 145 mL/kg/day of concentrated formula. This single study did not provide data regarding our primary outcome. No effects of the intervention were found on any of our secondary outcomes. The quality of the evidence from this study was graded low.

AUTHORS' CONCLUSIONS

There is no evidence to support the practice of fluid restriction in infants with early or established BPD.

Enteral feeding practices in the NICU: results from a 2009 Neonatal Enteral Feeding Survey

PURPOSE

: The purpose of this study was to examine the current management of the enteral feeding regimens of premature infants cared for in the neonatal intensive care unit (NICU).

SUBJECTS

: The study included responses from 70 neonatal nurses who participated in a 2009 Neonatal Enteral Feeding Survey distributed electronically to the National Association of Neonatal Nurses membership. These respondents were representative of both the United States and Canada, with 29 US states represented. The majority of respondents (95.7%) reported current nursing employment in a level III NICU.

DESIGN

: Survey research was used in this exploratory study. The survey, Enteral Tube Feeding Practices in the Neonatal Intensive Care Unit, was developed in collaboration with expert neonatal nurses and nutritionists, pilot tested, and distributed via electronic means.

METHODS

: Survey research was conducted according to the Dillman methodology. Data analysis included descriptive statistics and univariate analysis of variance assessing for significant differences in specific neonatal feeding practices reported. Thematic analysis was used to analyze the qualitative data reported.

OUTCOME MEASURES

: The outcome measures included the survey responses to the questions asked about the implementation of an enteral feeding protocol and various aspects of enteral feeding practices in the NICU.

RESULTS

: The majority of participants (60.9%) reported that an enteral feeding protocol was implemented in practice, but that it was inconsistently followed because of individual physician or nurse practice patterns, or highly individualized feeding plans required of specific clinical care needs of the patient. Respondents indicated that gestational age was the leading criteria used to initiate feedings, and patent ductus arteriosis treatment was the primary contraindication to enteral feedings. The leading factor reported to delay or alter enteral feedings was the presence of gastric residuals. Survey data indicated that other contraindicating factors to enteral feeding are variable across NICUs and, as reported, are often inconsistent with the current research published to date.

CONCLUSIONS

: Research is needed to provide a foundation on which to develop effective enteral feeding protocols that are appropriate for the diversity of infants cared for in the NICU. Such research findings will culminate in the development and implementation of enteral feeding protocols in the NICU, which will result in improved nutrition, growth, and development outcomes for premature infants.

Feeding problems in children with neonatal arterial ischemic stroke

Feeding disorders and the association of neonatal feeding disorders with other outcomes were assessed in a cohort of 84 children with neonatal arterial ischemic stroke at a tertiary children's hospital. Both chi(2) tests and Fisher's exact test were used to test associations. Forty-one of 84 children (48.8%) had feeding difficulties. Infarcted vascular territory (unilateral vs bilateral, P = .24) and neonatal seizures (P = .39) were not associated with feeding problems. Children with at least 1 perinatal comorbidity (P = .002, odds ratio = 4.27; 95% confidence interval: 1.65-11.03) and specifically respiratory problems (P = .004, odds ratio = 3.85; 95% confidence interval: 1.49-9.93) were significantly more likely to have feeding problems. Neonatal feeding problems were predictive of feeding problems at 12 to 24 months of age (P = .026, odds ratio = 3.33; 95% confidence interval: 1.12-9.90) but did not predict speech delay (P = .97) or cerebral palsy (P = .70). Feeding problems are important sequelae of neonatal stroke, but neonatal feeding problems in this group do not predict speech delay or cerebral palsy.

Medida de energia total do leite materno de mães de trigêmeos, gêmeos e filhos únicos

OBJETIVO: Comparar a energia total do leite materno de mães de trigêmeos, gêmeos e filhos únicos. MÉTODOS: Estudo transversal e controlado feito com mães usuárias do banco de leite do Hospital Israelita Albert Einstein. Foram analisadas seis amostras de leite materno de mães de trigêmeos, 13 de gêmeos e 17 de filhos únicos, coletadas sob paramentação, conforme normas técnicas da Rede Brasileira de Bancos de Leite Humano. A análise foi realizada por meio do teste de crematócrito e os resultados submetidos à análise de variância de Kuskal-Wallis. RESULTADOS: A energia total do leite materno de mães de trigêmeos apresentou mediana de calorias maior (651kcal/L), quando comparada à do leite de mães de filhos únicos (560kcal/L) (p<0,05). O leite das mães de gêmeos e o de mães de filhos únicos não foram diferentes. Os trigêmeos apresentaram peso ao nascer menor (mediana 1344g) em relação aos filhos únicos (1975g) (p<0,01). Não foi observada diferença estatística em relação à idade gestacional e à idade materna entre os três grupos de neonatos. CONCLUSÕES: Pode-se concluir que o presente estudo, o primeiro na literatura sobre o tema, apontou para a presença de maior valor de energia total no leite de mães de recém-nascidos trigemelares. Futuros estudos são necessários para elucidar os mecanismos envolvidos nesse achado.

Omega-3 Fatty Acid Supplementation in Perinatal Settings

The purpose of this article is (a) to explain the role of omega-3 fatty acids in human health, specifically in fetal/neonatal development, (b) to summarize the recent research behind the innovations in infant formula manufacturing and advertisement of omega-3 fatty acid supplementation for pregnant and lactating mothers, and (c) to relate the research findings to clinical practice. Omega-3 fatty acid supplementation in perinatal settings is discussed here from three vantage points: (a) supplementation of the third-trimester pregnant woman to enhance fetal development, (b) supplementation of the lactating mother to enhance development of the breastfeeding infant, and (c) supplementation of infant formulas to enhance development of the bottle-feeding infant. Supplementation can occur by increasing one's intake of foods high in omega-3 fatty acids or by ingesting fatty acid nutritional supplements. The challenge of supplementation for vegan and vegetarian women is also addressed.