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Challis P, Källén K, Björklund L, Elfvin A, Farooqi A, Håkansson S, Ley D, Norman M, Normann E, Serenius F, Sävman K, Hellström-Westas L, Um-Bergström P, Ådén U, Abrahamsson T, Domellöf M. Factors associated with the increased incidence of necrotising enterocolitis in extremely preterm infants in Sweden between two population-based national cohorts (2004-2007 vs 2014-2016). Arch Dis Child Fetal Neonatal Ed 2023; 109:87-93. [PMID: 37788898 PMCID: PMC10804036 DOI: 10.1136/archdischild-2023-325784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/28/2023] [Indexed: 10/05/2023]
Abstract
OBJECTIVE To investigate potential risk factors behind the increased incidence of necrotising enterocolitis (NEC) in Swedish extremely preterm infants. DESIGN Registry data from two population-based national cohorts were studied. NEC diagnoses (Bell stage ≥II) were validated against hospital records. PATIENTS All liveborn infants <27 weeks of gestation 2004-2007 (n=704) and 2014-2016 (n=895) in Sweden. MAIN OUTCOME MEASURES NEC incidence. RESULTS The validation process resulted in a 28% reduction of NEC cases but still confirmed a higher NEC incidence in the later epoch compared with the earlier (73/895 (8.2%) vs 27/704 (3.8%), p=0.001), while the composite of NEC or death was lower (244/895 (27.3%) vs 229/704 (32.5%), p=0.022). In a multivariable Cox regression model, censored for mortality, there was no significant difference in early NEC (0-7 days of life) between epochs (HR=0.9 (95% CI 0.5 to 1.9), p=0.9), but being born in the later epoch remained an independent risk factor for late NEC (>7 days) (HR=2.7 (95% CI 1.5 to 5.0), p=0.001). In propensity score analysis, a significant epoch difference in NEC incidence (12% vs 2.8%, p<0.001) was observed only in the tertile of infants at highest risk of NEC, where the 28-day mortality was lower in the later epoch (35% vs 50%, p=0.001). More NEC cases were diagnosed with intramural gas in the later epoch (33/73 (45.2%) vs 6/26 (23.1%), p=0.047). CONCLUSIONS The increase in NEC incidence between epochs was limited to cases occurring after 7 days of life and was partly explained by increased survival in the most extremely preterm infants. Misclassification of NEC is common.
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Affiliation(s)
- Pontus Challis
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Karin Källén
- Department of Clinical Sciences, Obstetrics and Gynecology, Lund University Faculty of Medicine, Lund, Sweden
| | - Lars Björklund
- Department of Clinical Sciences, Lund, Paediatrics, Lund University, Lund, Sweden
| | - Anders Elfvin
- Department of Pediatrics, Institute of Clinical Sciences, University of Gothenburg Sahlgrenska Academy, Gothenburg, Sweden
- Department of Pediatrics, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Aijaz Farooqi
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Stellan Håkansson
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - David Ley
- Department of Clinical Sciences, Lund, Paediatrics, Lund University, Lund, Sweden
| | - Mikael Norman
- Division of Pediatrics, Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Neonatal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Erik Normann
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Fredrik Serenius
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Karin Sävman
- Department of Pediatrics, Institute of Clinical Sciences, University of Gothenburg Sahlgrenska Academy, Gothenburg, Sweden
| | | | - Petra Um-Bergström
- Department of Pediatrics, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Clinical Science and Education at Södersjukhuset, Karolinska Institute, Stockholm, Sweden
| | - Ulrika Ådén
- Division of Pediatrics, Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden
- Departments of Biomedical and Clinical Sciences and Pediatrics, Linköping University, Linköping, Sweden
| | - Thomas Abrahamsson
- Departments of Biomedical and Clinical Sciences and Pediatrics, Linköping University, Linköping, Sweden
- Department of Pediatrics, Linköping University Hospital, Linköping, Sweden
| | - Magnus Domellöf
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
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Embleton ND, Jennifer Moltu S, Lapillonne A, van den Akker CHP, Carnielli V, Fusch C, Gerasimidis K, van Goudoever JB, Haiden N, Iacobelli S, Johnson MJ, Meyer S, Mihatsch W, de Pipaon MS, Rigo J, Zachariassen G, Bronsky J, Indrio F, Köglmeier J, de Koning B, Norsa L, Verduci E, Domellöf M. Enteral Nutrition in Preterm Infants (2022): A Position Paper From the ESPGHAN Committee on Nutrition and Invited Experts. J Pediatr Gastroenterol Nutr 2023; 76:248-268. [PMID: 36705703 DOI: 10.1097/mpg.0000000000003642] [Citation(s) in RCA: 59] [Impact Index Per Article: 59.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES To review the current literature and develop consensus conclusions and recommendations on nutrient intakes and nutritional practice in preterm infants with birthweight <1800 g. METHODS The European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Committee of Nutrition (CoN) led a process that included CoN members and invited experts. Invited experts with specific expertise were chosen to represent as broad a geographical spread as possible. A list of topics was developed, and individual leads were assigned to topics along with other members, who reviewed the current literature. A single face-to-face meeting was held in February 2020. Provisional conclusions and recommendations were developed between 2020 and 2021, and these were voted on electronically by all members of the working group between 2021 and 2022. Where >90% consensus was not achieved, online discussion meetings were held, along with further voting until agreement was reached. RESULTS In general, there is a lack of strong evidence for most nutrients and topics. The summary paper is supported by additional supplementary digital content that provide a fuller explanation of the literature and relevant physiology: introduction and overview; human milk reference data; intakes of water, protein, energy, lipid, carbohydrate, electrolytes, minerals, trace elements, water soluble vitamins, and fat soluble vitamins; feeding mode including mineral enteral feeding, feed advancement, management of gastric residuals, gastric tube placement and bolus or continuous feeding; growth; breastmilk buccal colostrum, donor human milk, and risks of cytomegalovirus infection; hydrolyzed protein and osmolality; supplemental bionutrients; and use of breastmilk fortifier. CONCLUSIONS We provide updated ESPGHAN CoN consensus-based conclusions and recommendations on nutrient intakes and nutritional management for preterm infants.
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Affiliation(s)
| | | | | | - Chris H P van den Akker
- the Department of Pediatrics - Neonatology, Amsterdam UMC - Emma Children's Hospital, University of Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Virgilio Carnielli
- Polytechnic University of Marche and Division of Neonatology, Ospedali Riuniti, Ancona, Ancona, Italy
| | - Christoph Fusch
- the Department of Pediatrics, Nuremberg General Hospital, Paracelsus Medical School, Nuremberg, Germany
- the Division of Neonatology, Department of Pediatrics, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Konstantinos Gerasimidis
- the Human Nutrition, School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - Johannes B van Goudoever
- Amsterdam UMC, University of Amsterdam, Vrije Universiteit, Emma Children's Hospital, Amsterdam, The Netherlands
| | - Nadja Haiden
- the Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Silvia Iacobelli
- the Réanimation Néonatale et Pédiatrique, Néonatologie - CHU La Réunion, Saint-Pierre, France
| | - Mark J Johnson
- the Department of Neonatal Medicine, University Hospital Southampton NHS Trust, Southampton, UK
- the National Institute for Health Research Biomedical Research Centre Southampton, University Hospital Southampton NHS Trust and University of Southampton, Southampton, UK
| | - Sascha Meyer
- the Department of General Paediatrics and Neonatology, University Hospital of Saarland, Homburg, Germany
| | - Walter Mihatsch
- the Department of Pediatrics, Ulm University, Ulm, Germany
- the Department of Health Management, Neu-Ulm University of Applied Sciences, Neu-Ulm, Germany
| | - Miguel Saenz de Pipaon
- the Department of Pediatrics-Neonatology, La Paz University Hospital, Autonoma University of Madrid, Madrid, Spain
| | - Jacques Rigo
- the Neonatal Unit, University of Liège, CHR Citadelle, Liège, Belgium
| | - Gitte Zachariassen
- H.C. Andersen Children's Hospital, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - Jiri Bronsky
- the Department of Paediatrics, University Hospital Motol, Prague, Czech Republic
| | - Flavia Indrio
- the Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Jutta Köglmeier
- the Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Barbara de Koning
- the Paediatric Gastroenterology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Lorenzo Norsa
- the Paediatric Hepatology, Gastroenterology and Transplantation, ASST Papa Giovanni XXIIII, Bergamo, Italy
| | - Elvira Verduci
- the Department of Health Sciences, University of Milan, Milan, Italy
- the Department of Paediatrics, Ospedale dei Bambini Vittore Buzzi, Milan, Italy
| | - Magnus Domellöf
- the Department of Clinical Sciences, Paediatrics, Umeå University, Umeå, Sweden
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Lund AM, Domellöf M, Pivodic A, Hellström A, Stoltz Sjöström E, Hansen-Pupp I. Mother's Own Milk and Its Relationship to Growth and Morbidity in a Population-based Cohort of Extremely Preterm Infants. J Pediatr Gastroenterol Nutr 2022; 74:292-300. [PMID: 34759238 PMCID: PMC8788942 DOI: 10.1097/mpg.0000000000003352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 10/27/2021] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The aim of the study was to evaluate the relationships between intake of mother's own milk (MOM), compared with intake of pasteurized donor milk (DM), and postnatal growth, incidence of retinopathy of prematurity (ROP) and bronchopulmonary dysplasia (BPD), in extremely preterm infants. METHODS Swedish population-based cohort of surviving extremely preterm infants born 2004 to 2007. Exposure to MOM and DM was investigated from birth until 32 weeks postmenstrual age (PMA) in 453 infants. Primary outcome variables were change in z-score (Δ) from birth to 32 weeks PMA for weight, length, and head circumference (HC). Secondary outcomes were incidence of ROP and BPD. Mixed models adjusting for confounders were used to investigate the association between exposures and outcomes. RESULTS Infants' mean gestational age (GA) was 25.4 weeks. Unadjusted, MOM (per 10 mL · kg-1 · day-1) was associated with Δweight and ΔHC with beta estimates of 0.03 z-score units (95% CI, 0.02-0.04, P < 0.001) and 0.03 z-score units (95% CI, 0.01-0.05, P = 0.003), respectively. After adjustment for predefined confounders, the association remained significant for Δweight and ΔHC. A similar pattern was found between Δweight and each 10% increase of MOM. Unadjusted, a higher intake of MOM (mL · kg-1 · day-1) was significantly associated to a lower probability of any ROP and severe ROP; however, these associations did not remain in the adjusted analyses. No associations were found between MOM (mL · kg-1 · day-1) and BPD. Moreover, no associations were found between DM and growth or morbidity outcomes. CONCLUSIONS An increased intake of MOM, as opposed to DM (and not formula feeding), was associated with improved postnatal weight gain and HC growth from birth until 32 weeks PMA in extremely preterm infants. Interventions aiming at increasing early intake of unpasteurized MOM for extremely preterm infants should be encouraged.
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Affiliation(s)
- Anna-My Lund
- Division of Paediatrics, Department of Clinical Sciences, Lund, Lund University and Skåne University Hospital
| | - Magnus Domellöf
- Division of Paediatrics, Department of Clinical Sciences, Umeå University
| | - Aldina Pivodic
- Section for Ophthalmology, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg
| | - Ann Hellström
- Section for Ophthalmology, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg
| | | | - Ingrid Hansen-Pupp
- Division of Paediatrics, Department of Clinical Sciences, Lund, Lund University and Skåne University Hospital
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Perioperative nutrition in extremely preterm infants undergoing surgery for patent ductus arteriosus. CLINICAL NUTRITION EXPERIMENTAL 2020. [DOI: 10.1016/j.yclnex.2020.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Lund A, Löfqvist C, Pivodic A, Lundgren P, Hård A, Hellström A, Hansen‐Pupp I. Unpasteurised maternal breast milk is positively associated with growth outcomes in extremely preterm infants. Acta Paediatr 2020; 109:1138-1147. [PMID: 31747093 PMCID: PMC9541184 DOI: 10.1111/apa.15102] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 09/06/2019] [Accepted: 11/18/2019] [Indexed: 12/13/2022]
Abstract
AIM Extrauterine growth restriction is common among extremely preterm infants. We explored whether intake of unpasteurised maternal milk (MM) and pasteurised donor milk (DM) was associated with longitudinal growth outcomes and neonatal morbidities in extremely preterm infants. METHODS Observational study of 90 preterm infants born between 2013 and 2015 in Gothenburg, Sweden. Data were prospectively collected on nutritional and breast milk intakes during the first 28 days. RESULTS Ninety infants (39 girls and 51 boys) with a median gestational age of 25.3 (22.7-27.9) weeks were evaluated. MM intake (mL/kg/d) correlated positively with almost all z-scores for weight, length and head circumference at 28 postnatal days and at postmenstrual age (PMA) 32 and 36 weeks. After multivariable adjustment, MM intake and weight z-score at 28 postnatal days and at PMA 32 and 36 weeks remained significantly associated. Infants consuming ≥80% MM had more favourable weight z-scores at PMA 32 and 36 weeks. Intake of DM did not correlate with any growth outcomes. Infants without retinopathy of prematurity had a significantly higher intake of MM (mL/kg/d). CONCLUSION Unpasteurised MM was positively associated with longitudinal growth outcomes. Motivating mothers to provide their infants with their own milk after preterm birth should be emphasised.
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Affiliation(s)
- Anna‐My Lund
- Department of Clinical Sciences, Paediatrics Skåne University Hospital Lund University Lund Sweden
| | - Chatarina Löfqvist
- Section for Opthalmology Department of Clinical Neuroscience Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
| | - Aldina Pivodic
- Section for Opthalmology Department of Clinical Neuroscience Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
| | - Pia Lundgren
- Section for Opthalmology Department of Clinical Neuroscience Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
| | - Anna‐Lena Hård
- Section for Opthalmology Department of Clinical Neuroscience Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
| | - Ann Hellström
- Section for Opthalmology Department of Clinical Neuroscience Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
| | - Ingrid Hansen‐Pupp
- Department of Clinical Sciences, Paediatrics Skåne University Hospital Lund University Lund Sweden
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Torbjörnsdotter T, Marosvari‐Barna E, Henckel E, Corrias M, Norgren S, Janson A. Successful treatment of a cohort of infants with neonatal diabetes using insulin pumps including data on genetics and estimated incidence. Acta Paediatr 2020; 109:1131-1137. [PMID: 31746017 DOI: 10.1111/apa.15100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 11/11/2019] [Accepted: 11/18/2019] [Indexed: 11/29/2022]
Abstract
AIM Neonatal diabetes is rare, and treatment is challenging. We present aspects on treatment, genetics and incidence. METHOD This was a prospective cohort study including all cases in our study area in Sweden. We compared with data from the National Diabetes Registry, the Neonatal Quality Register and the National Patient Register. RESULTS In the 19-year study period January 1, 1998 to December 31, 2016, we treated seven infants, five of them boys. Six patients used a subcutaneous insulin pump, and the smallest patient started at a weight of 938 g. Most important was for the pump to deliver minute doses of insulin and the design of cannulas and tubing. All patients could stop insulin treatment at 17-145 days of age. One patient relapsed at age 4.5 years. Four patients used the insulin pump after discharge. A mutation was identified in five patients, and this included all patients born after 30 weeks of gestation. The incidence of neonatal diabetes was 2/1 00 000, higher than previously estimated for Europe. Similar but lower incidences were reported in the registries. CONCLUSION Insulin pumps were safe in neonatal diabetes. All seven cases were transient. Neonatal diabetes was more common in our area than reported from Europe.
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Affiliation(s)
| | | | - Ewa Henckel
- Neonatal Intensive Care Unit Karolinska University Hospital Huddinge Sweden
- Division of Pediatrics Department of Clinical Science, Intervention and Technology Karolinska Institutet Huddinge Sweden
| | - Martino Corrias
- Neonatal Intensive Care Unit Karolinska University Hospital Huddinge Sweden
| | - Svante Norgren
- Pediatric Diabetes Unit Karolinska University Hospital Huddinge Sweden
- Division of Pediatric Endocrinology Department of Women´s and Children´s Health Karolinska Institutet Stockholm Sweden
| | - Annika Janson
- Pediatric Diabetes Unit Karolinska University Hospital Huddinge Sweden
- Division of Pediatric Endocrinology Department of Women´s and Children´s Health Karolinska Institutet Stockholm Sweden
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Chmielewska A, Farooqi A, Domellöf M, Ohlund I. Lean Tissue Deficit in Preterm Infants Persists up to 4 Months of Age: Results from a Swedish Longitudinal Study. Neonatology 2020; 117:80-87. [PMID: 31822002 DOI: 10.1159/000503292] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 09/10/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND At term-equivalent age, infants born prematurely are shorter, lighter and have more adipose tissue compared to term counterparts. Little is known on whether the differences in body composition persist in later age. METHODS We prospectively recruited 33 preterm infants (<32 weeks gestational age, mean gestational age 28.1 weeks) and 69 term controls. Anthropometry and body composition (air displacement plethysmography) were monitored up to 4 months of age. Nutrient intakes from preterm infants were collected from clinical records. RESULTS At 4 months of age preterm infants were lighter and shorter than term controls (mean weight-for-age z-score: -0.73 vs. 0.06, p = 0.001; mean length-for-age z-score: -1.31 vs. 0.29, p < 0.0001). The significantly greater percentage of total body fat seen in preterm infants at term-equivalent age (20.2 vs. 11.7%, p < 0.0001) was no longer observed at 4 months. A deficit of fat-free mass persisted until 4 months of age (fat-free mass at term-equivalent age: 2.71 vs. 3.18 kg, p < 0.0001; at 4 months: 4.3 vs. 4.78 kg, p < 0.0001). The fat mass index and fat-free mass index (taking length into account) did not differ between the groups. Nutrition had little effect on body composition. Higher protein intake at week 2 was a negative predictor of fat-free mass at discharge. CONCLUSIONS At 4 months corrected age, preterm infants were both lighter and shorter than term controls and the absolute fat-free mass deficit remained until this age. Little effect of nutrition on body composition was observed.
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Affiliation(s)
- Anna Chmielewska
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden,
| | - Aijaz Farooqi
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Magnus Domellöf
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Inger Ohlund
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
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Sahin S, Ozdemir T, Katipoglu N, Akcan AB, Kaynak Turkmen M. Comparison of Changes in Breast Milk Macronutrient Content During the First Month in Preterm and Term Infants. Breastfeed Med 2020; 15:56-62. [PMID: 31765240 DOI: 10.1089/bfm.2019.0141] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Purpose: This study aims to achieve a better understanding of the trend of maternal milk macronutrient levels by analyzing protein, lipid, carbohydrate, and energy content of the breast milk and investigate the possible confounders of macronutrient content during the first 4 weeks of lactation to meet the specific needs of babies, guide optimum fortification of maternal milk. Patients and Methods: Breast milk from 39 mothers who had delivered preterm infants and 21 mothers of term infants were collected longitudinally for the first 4 weeks of lactation. Fresh milk samples were obtained on day 3, 7, 14, and 28 of lactation. The samples are analyzed using mid-infrared milk analyzer (MIRIS Human Milk Analyzer, HMA; Miris AB, Uppsala, Sweden). Results: Colostral milk protein concentrations of mothers of both preterm and term infants were significantly higher and the protein content of the samples decreased in time, according to the week of lactation during the study period. In contrast, fat, carbohydrate, and energy content were lowest in the colostral milk in both groups. When preterm and term milks were compared, fat and carbohydrate levels on 28th day and energy levels on 14th and 28th days were significantly higher in term milks, whereas no difference in protein contents were observed between the two groups on each time period. Mode of delivery was found to have statistically significant correlation with protein content of the milk. Conclusion: This longitudinal study revealed significant changes in analyzed macronutrient contents of mother's milk over the first 4 week period.
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Affiliation(s)
- Suzan Sahin
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine, Adnan Menderes University, Aydin, Turkey
| | - Tuba Ozdemir
- Department of Pediatrics, Faculty of Medicine, Adnan Menderes University, Aydin, Turkey
| | - Nagehan Katipoglu
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine, Adnan Menderes University, Aydin, Turkey
| | - Abdullah Barıs Akcan
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine, Adnan Menderes University, Aydin, Turkey
| | - Munevver Kaynak Turkmen
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine, Adnan Menderes University, Aydin, Turkey
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Hård A, Nilsson AK, Lund A, Hansen‐Pupp I, Smith LEH, Hellström A. Review shows that donor milk does not promote the growth and development of preterm infants as well as maternal milk. Acta Paediatr 2019; 108:998-1007. [PMID: 30565323 PMCID: PMC6520191 DOI: 10.1111/apa.14702] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 10/09/2018] [Accepted: 12/12/2018] [Indexed: 12/28/2022]
Abstract
Aim This nonsystematic review examined differences in the composition of raw maternal breastmilk and pasteurised donor milk and possible health effects on preterm infants. Methods We searched PubMed up to July 2018 for studies published in English that focused on four comparisons as follows: raw maternal milk versus donor milk, human milk before and after Holder pasteurisation, milk from mothers who delivered preterm and at term and milk collected during early and late lactation. We also searched for possible effects of the milk components, as well as the effects of maternal and donor milk on preterm infants’ health. Results Raw maternal milk contained factors involved in antioxidant and anti‐inflammatory defence, gut microbiome establishment and the maturation of immune defences, food tolerability and metabolism. Many of these factors were reduced or abolished in processed donor milk. Both maternal milk and donor milk have been associated with a reduced incidence of necrotising enterocolitis. High‐dose feeding with maternal milk during the neonatal period reportedly reduced the risk of other morbidities and promoted growth and neurodevelopment. Conclusion Many of the components in raw maternal breastmilk were lacking in pasteurised donor milk, which was inferior in promoting the growth and development of very preterm infants.
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Affiliation(s)
- Anna‐Lena Hård
- Department of Ophthalmology Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
| | - Anders K. Nilsson
- Department of Ophthalmology Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
| | - Anna‐My Lund
- Department of Pediatrics Institute of Clinical Sciences Lund Lund University and Skane University Hospital Lund Sweden
| | - Ingrid Hansen‐Pupp
- Department of Pediatrics Institute of Clinical Sciences Lund Lund University and Skane University Hospital Lund Sweden
| | - Lois E. H. Smith
- Department of Ophthalmology Boston Children's Hospital Harvard Medical School Boston MA USA
| | - Ann Hellström
- Department of Ophthalmology Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
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Challis P, Larsson L, Stoltz Sjöström E, Serenius F, Domellöf M, Elfvin A. Validation of the diagnosis of necrotising enterocolitis in a Swedish population-based observational study. Acta Paediatr 2019; 108:835-841. [PMID: 30238614 PMCID: PMC6586065 DOI: 10.1111/apa.14585] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 09/17/2018] [Indexed: 12/29/2022]
Abstract
Aim The definition of necrotising enterocolitis (NEC) is based on clinical and radiological signs that can be difficult to interpret. The aim of the present study was to validate the incidence of NEC in the Extremely Preterm Infants in Sweden Study (EXPRESS) Methods The EXPRESS study consisted of all 707 infants born before 27 + 0 gestational weeks during the years 2004–2007 in Sweden. Of these infants, 38 were recorded as having NEC of Bell stage II or higher. Hospital records were obtained for these infants. Furthermore, to identify missed cases, all infants with a sudden reduction of enteral nutrition, in the EXPRESS study were identified (n = 71). Hospital records for these infants were obtained. Thus, 108 hospital records were obtained and scored independently by two neonatologists for NEC. Results Of 38 NEC cases in the EXPRESS study, 26 were classified as NEC after validation. Four cases not recorded in the EXPRESS study were found. The incidence of NEC decreased from 6.3% to 4.3%. Conclusion Validation of the incidence of NEC revealed over‐ and underestimation of NEC in the EXPRESS study despite carefully collected data. Similar problems may occur in other national data sets or quality registers.
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Affiliation(s)
- Pontus Challis
- Department of Clinical Sciences Paediatrics Umeå University Umeå Sweden
| | - Linn Larsson
- Department of Clinical Sciences Paediatrics Umeå University Umeå Sweden
| | | | - Fredrik Serenius
- Department of Clinical Sciences Paediatrics Umeå University Umeå Sweden
- Department of Women's and Children's Health Uppsala University Uppsala Sweden
| | - Magnus Domellöf
- Department of Clinical Sciences Paediatrics Umeå University Umeå Sweden
| | - Anders Elfvin
- Institution of Clinical Sciences Department of Pediatrics Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
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Zamir I, Stoltz Sjöström E, Edstedt Bonamy AK, Mohlkert LA, Norman M, Domellöf M. Postnatal nutritional intakes and hyperglycemia as determinants of blood pressure at 6.5 years of age in children born extremely preterm. Pediatr Res 2019; 86:115-121. [PMID: 30776793 PMCID: PMC6760565 DOI: 10.1038/s41390-019-0341-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 01/16/2019] [Accepted: 02/01/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND Adverse developmental programming by early-life exposures might account for higher blood pressure (BP) in children born extremely preterm. We assessed associations between nutrition, growth and hyperglycemia early in infancy, and BP at 6.5 years of age in children born extremely preterm. METHODS Data regarding perinatal exposures including nutrition, growth and glycemia status were collected from the Extremely Preterm Infants in Sweden Study (EXPRESS), a population-based cohort including infants born <27 gestational weeks during 2004-2007. BP measurements were performed at 6.5 years of age in a sub-cohort of 171 children (35% of the surviving children). RESULTS Higher mean daily protein intake (+1 g/kg/day) during postnatal weeks 1-8 was associated with 0.40 (±0.18) SD higher diastolic BP. Higher mean daily carbohydrate intake (+1 g/kg/day) during the same period was associated with 0.18 (±0.05) and 0.14 (±0.04) SD higher systolic and diastolic BP, respectively. No associations were found between infant growth (weight, length) and later BP. Hyperglycemia and its duration during postnatal weeks 1-4 were associated primarily with higher diastolic BP z-scores. CONCLUSIONS These findings emphasize the importance of modifiable early-life exposures, such as nutrition and hyperglycemia, in determining long-term outcomes in children born extremely preterm.
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Affiliation(s)
- Itay Zamir
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden.
| | | | - Anna-Karin Edstedt Bonamy
- 0000 0004 1937 0626grid.4714.6Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden ,0000 0004 1937 0626grid.4714.6Clinical Epidemiology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden ,0000 0000 8986 2221grid.416648.9Sachs’ Children’s and Youth Hospital, Södersjukhuset, Stockholm, Sweden
| | - Lilly-Ann Mohlkert
- 0000 0000 8986 2221grid.416648.9Sachs’ Children’s and Youth Hospital, Södersjukhuset, Stockholm, Sweden ,0000 0004 1937 0626grid.4714.6Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Mikael Norman
- 0000 0000 8986 2221grid.416648.9Sachs’ Children’s and Youth Hospital, Södersjukhuset, Stockholm, Sweden ,0000 0000 9241 5705grid.24381.3cDepartment of Neonatal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Magnus Domellöf
- 0000 0001 1034 3451grid.12650.30Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
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12
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Zamir I, Tornevi A, Abrahamsson T, Ahlsson F, Engström E, Hallberg B, Hansen-Pupp I, Sjöström ES, Domellöf M. Hyperglycemia in Extremely Preterm Infants-Insulin Treatment, Mortality and Nutrient Intakes. J Pediatr 2018; 200:104-110.e1. [PMID: 29731360 DOI: 10.1016/j.jpeds.2018.03.049] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 03/05/2018] [Accepted: 03/19/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To explore the prevalence of hyperglycemia and the associations between nutritional intakes, hyperglycemia, insulin treatment, and mortality in extremely preterm infants. STUDY DESIGN Prospectively collected data from the Extremely Preterm Infants in Sweden Study (EXPRESS) was used in this study and included 580 infants born <27 gestational weeks during 2004-2007. Available glucose measurements (n = 9850) as well as insulin treatment and nutritional data were obtained retrospectively from hospital records for the first 28 postnatal days as well as 28- and 70-day mortality data. RESULTS Daily prevalence of hyperglycemia >180 mg/dL (10 mmol/L) of up to 30% was observed during the first 2 postnatal weeks, followed by a slow decrease in its occurrence thereafter. Generalized additive model analysis showed that increasing parenteral carbohydrate supply with 1 g/kg/day was associated with a 1.6% increase in glucose concentration (P < .001). Hyperglycemia was associated with more than double the 28-day mortality risk (P < .01). In a logistic regression model, insulin treatment was associated with lower 28- and 70-day mortality when given to infants with hyperglycemia irrespective of the duration of the hyperglycemic episode (P < .05). CONCLUSIONS Hyperglycemia is common in extremely preterm infants throughout the first postnatal month. Glucose infusions seem to have only a minimal impact on glucose concentrations. In the EXPRESS cohort, insulin treatment was associated with lower mortality in infants with hyperglycemia. Current practices of hyperglycemia treatment in extremely preterm infants should be reevaluated and assessed in randomized controlled clinical trials.
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Affiliation(s)
- Itay Zamir
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden.
| | - Andreas Tornevi
- Department of Public Health and Clinical Medicine, Division of Occupational and Environmental Medicine, Umeå University, Umeå, Sweden
| | - Thomas Abrahamsson
- Department of Clinical and Experimental Medicine, Division of Pediatrics, Linköping University, Linköping, Sweden
| | - Fredrik Ahlsson
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Eva Engström
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Boubou Hallberg
- CLINTEC Department of Neonatology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Ingrid Hansen-Pupp
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Pediatrics, Lund, Sweden
| | | | - Magnus Domellöf
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
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13
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Klevebro S, Westin V, Stoltz Sjöström E, Norman M, Domellöf M, Edstedt Bonamy AK, Hallberg B. Early energy and protein intakes and associations with growth, BPD, and ROP in extremely preterm infants. Clin Nutr 2018; 38:1289-1295. [PMID: 29885776 DOI: 10.1016/j.clnu.2018.05.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 04/03/2018] [Accepted: 05/21/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIM Extremely preterm infants face substantial neonatal morbidity. Nutrition is important to promote optimal growth and organ development in order to reduce late neonatal complications. The aim of this study was to examine the associations of early nutritional intakes on growth and risks of bronchopulmonary dysplasia (BPD) and retinopathy of prematurity (ROP) in a high-risk population. METHODS This population-based cohort study includes infants born before 27 0/7 weeks of gestational age without severe malformations and surviving ≥10 days. Intake of energy and protein on postnatal days 4-6 and association with weight standard deviation score (WSDS) from birth to day 7, as well as intakes of energy and protein on postnatal days 4-6 and 7 to 27, respectively, and association with composite outcome of death and BPD and separate outcomes of BPD and ROP were examined, and adjusted for potential confounders. RESULTS The cohort comprised 296 infants with a median gestational age of 25 3/7 weeks. Expressed as daily intakes, every additional 10 kcal/kg/d of energy during days 4-6 was associated with 0.08 higher WSDS on day 7 (95% CI 0.06-0.11; p < 0.001). Between days 7 and 27, every 10 kcal/kg/d increase in energy intake was associated with a reduced risk of BPD of 9% (95% CI 1-16; p = 0.029) and any grade of ROP with a reduced risk of 6% (95% CI 2-9; p = 0.005) in multivariable models. This association was statistically significant in infants with ≤10 days of mechanical ventilation. In infants with >10 days of mechanical ventilation, a combined higher intake of energy and protein was associated with a reduced risk of BPD. CONCLUSION Early provision of energy and protein may reduce postnatal weight loss and risk of morbidity in extremely preterm infants.
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Affiliation(s)
- Susanna Klevebro
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Sachs' Children and Youth Hospital, South General Hospital, Stockholm, Sweden.
| | - Vera Westin
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Function Area Clinical Nutrition, Karolinska University Hospital, Stockholm, Sweden
| | | | - Mikael Norman
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Neonatal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Magnus Domellöf
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Anna-Karin Edstedt Bonamy
- Sachs' Children and Youth Hospital, South General Hospital, Stockholm, Sweden; Department of Women's and Children's Health and Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden
| | - Boubou Hallberg
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Neonatal Medicine, Karolinska University Hospital, Stockholm, Sweden
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14
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Newkirk M, Shakeel F, Parimi P, Rothpletz-Puglia P, Patusco R, Marcus AF, Brody R. Comparison of Calorie and Protein Intake of Very Low Birth Weight Infants Receiving Mother's Own Milk or Donor Milk When the Nutrient Composition of Human Milk Is Measured With a Breast Milk Analyzer. Nutr Clin Pract 2018; 33:679-686. [DOI: 10.1002/ncp.10060] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Melanie Newkirk
- Maternal; Fetal, Neonatal Institute; Johns Hopkins All Children's Hospital; St. Petersburg Florida USA
- Department of Nutritional Sciences Graduate Programs in Clinical Nutrition; School of Health Professions; Rutgers; The State University of New Jersey; Rutgers New Jersey USA
| | - Fauzia Shakeel
- Maternal; Fetal, Neonatal Institute; Johns Hopkins All Children's Hospital; St. Petersburg Florida USA
| | - Prabhu Parimi
- Maternal; Fetal, Neonatal Institute; Johns Hopkins All Children's Hospital; St. Petersburg Florida USA
| | - Pamela Rothpletz-Puglia
- Department of Nutritional Sciences Graduate Programs in Clinical Nutrition; School of Health Professions; Rutgers; The State University of New Jersey; Rutgers New Jersey USA
| | - Rachael Patusco
- Department of Nutritional Sciences Graduate Programs in Clinical Nutrition; School of Health Professions; Rutgers; The State University of New Jersey; Rutgers New Jersey USA
| | - Andrea Fleisch Marcus
- Department of Nutritional Sciences Graduate Programs in Clinical Nutrition; School of Health Professions; Rutgers; The State University of New Jersey; Rutgers New Jersey USA
| | - Rebecca Brody
- Department of Nutritional Sciences Graduate Programs in Clinical Nutrition; School of Health Professions; Rutgers; The State University of New Jersey; Rutgers New Jersey USA
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15
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Ng DVY, Unger S, Asbury M, Kiss A, Bishara R, Bando N, Tomlinson C, Gibbins S, O'Connor DL. Neonatal Morbidity Count Is Associated With a Reduced Likelihood of Achieving Recommendations for Protein, Lipid, and Energy in Very Low Birth Weight Infants: A Prospective Cohort Study. JPEN J Parenter Enteral Nutr 2017; 42:623-632. [PMID: 28537798 DOI: 10.1177/0148607117710441] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 04/27/2017] [Indexed: 01/02/2023]
Abstract
BACKGROUND Serious morbidity may elevate nutrient requirements and affect adherence to feeding guidelines for very low birth weight (VLBW) infants. An understanding of factors affecting nutrient intakes of VLBW infants will facilitate development of strategies to improve nutrient provision. Our aim was to examine the impact of neonatal morbidity count on achieving recommended nutrient intakes in VLBW infants. METHODS VLBW infants enrolled in the Donor Milk for Improved Neurodevelopmental Outcomes trial (ISRCTN35317141, n = 363) were included. Serious morbidities and daily parenteral and enteral intakes were collected prospectively. RESULTS Median intakes of infants with and without ≥1 morbidity met protein recommendations (3.5-4.5 g/kg/d) by week 2, although not maintained after week 4. Infants with ≥1 morbidity (vs without) were 2 weeks slower in achieving lipid (4.8-6.6 g/kg/d; week 4 vs 2) and energy (110-130 kcal/kg/d; week 5 vs 3) and 1 week slower in achieving carbohydrate recommendations (11.6-13.2 g/kg/d; week 4 vs 3). Adjusted hazard ratios of first achieving recommendations on any given day in infants with any 1 or 2 morbidities were 0.6 (95% confidence interval [CI], 0.5-0.9) and 0.6 (0.4-0.9), respectively, for protein; 0.5 (0.4-0.7) and 0.3 (0.2-0.5) for lipid; and 0.5 (0.4-0.7) and 0.3 (0.2-0.4) for energy. CONCLUSION Morbidity is associated with a decreased likelihood of achieving lipid and consequently energy recommendations. This and the decline in protein intakes after the early neonatal period require further investigation to ensure optimal nutrition in this vulnerable population.
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Affiliation(s)
- Dawn V Y Ng
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada.,SickKids Research Institute, Toronto, Ontario, Canada
| | - Sharon Unger
- SickKids Research Institute, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Michelle Asbury
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada.,SickKids Research Institute, Toronto, Ontario, Canada
| | - Alex Kiss
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Rosine Bishara
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Nicole Bando
- SickKids Research Institute, Toronto, Ontario, Canada
| | - Chris Tomlinson
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada.,SickKids Research Institute, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | | | - Deborah L O'Connor
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada.,SickKids Research Institute, Toronto, Ontario, Canada.,Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada
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16
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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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17
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Abstract
Human milk analyzers can measure macronutrient content in native breast milk to tailor adequate supplementation with fortifiers. This article reviews all studies using milk analyzers, including (i) evaluation of devices, (ii) the impact of different conditions on the macronutrient analysis of human milk, and (iii) clinical trials to improve growth. Results lack consistency, potentially due to systematic errors in the validation of the device, or pre-analytical sample preparation errors like homogenization. It is crucial to introduce good laboratory and clinical practice when using these devices; otherwise a non-validated clinical usage can severely affect growth outcomes of infants.
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18
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Mimouni FB, Lubetzky R, Yochpaz S, Mandel D. Preterm Human Milk Macronutrient and Energy Composition: A Systematic Review and Meta-Analysis. Clin Perinatol 2017; 44:165-172. [PMID: 28159203 DOI: 10.1016/j.clp.2016.11.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
This study is a systematic review of the macronutrient and energy composition of preterm human milk to enable the practicing neonatologist to make informed nutritional decisions in preterm infants. Meta-analyses were conducted in all the studies that reported total energy, true protein, fat, and lactose. Protein content decreased massively (by one-half) and significantly from day 1 to 3 at week 10 to 12. There was a significant linear increase in fat, lactose, and energy content during the same timeframe. Theoretic calculations on energy and macronutrient intake of preterm infants must be made according to a lactation time-specific manner.
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Affiliation(s)
- Francis B Mimouni
- Department of Neonatology, Shaare Zedek Medical Center, 12 Shmuel Bait Street, Jerusalem 913102, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronit Lubetzky
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Pediatrics, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, 6 Weizman Street, Tel Aviv 64239, Israel
| | - Sivan Yochpaz
- Department of Pediatrics, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, 6 Weizman Street, Tel Aviv 64239, Israel
| | - Dror Mandel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Neonatology, Dana Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, 6 Weizman Street, Tel Aviv 64239, Israel.
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19
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Arnold M, Adamkin D, Radmacher P. Improving fortification with weekly analysis of human milk for VLBW infants. J Perinatol 2017; 37:194-196. [PMID: 27684418 DOI: 10.1038/jp.2016.170] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 08/29/2016] [Accepted: 08/31/2016] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To track individual mother's macronutrient variability in preterm human milk (HM) over 6 weeks of lactation. STUDY DESIGN This was a prospective, observational study of mother's own milk from women who delivered a very low birth weight infant (<1500 g). A single, random maternal breast milk sample was collected and analyzed weekly for 6 consecutive weeks. Analysis was by mid-infrared spectroscopy. RESULTS Twenty women consented to provide at least one milk sample. Fat, protein and energy content varied widely among mothers and by week of lactation. Energy content ranged from 9.5 to 30.4 kcal oz-1 across the study period. Twenty-five percent of all samples had an energy content <17 kcal oz-1. Protein content ranged from 1.1 to 2.8 g dl-1 in the first week. Sixty-three percent of all samples had a protein content <1.5 g dl-1. Fat and energy showed trends of increasing concentrations, whereas protein showed the expected decline over time. Lactose showed little variability by woman or by week of lactation. CONCLUSION HM fat and protein content varied widely by individual woman over time. Week-to-week variability in fat and protein can impact growth. The ability to analyze HM is helpful to improve fortification of HM.
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Affiliation(s)
- M Arnold
- Division of Neonatal Medicine, University of Louisville School of Medicine, Neonatal Nutrition Research Lab, Louisville, KY, USA
| | - D Adamkin
- Division of Neonatal Medicine, University of Louisville School of Medicine, Neonatal Nutrition Research Lab, Louisville, KY, USA
| | - P Radmacher
- Division of Neonatal Medicine, University of Louisville School of Medicine, Neonatal Nutrition Research Lab, Louisville, KY, USA
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20
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Abstract
Fatty acids are critical nutrient regulators of intracellular signaling and influence key pathways including inflammatory responses, hemostasis as well as central nervous system development and function. Preterm birth interrupts the maternal-fetal transfer of essential fatty acids including docosahexaenoic and arachidonic acids, which occurs during the third trimester. Postnatal deficits of these nutrients accrue in preterm infants during the first week and they remain throughout the first months. Due to the regulatory roles of these fatty acids, such deficits contribute an increased risk of developing prematurity-related morbidities including impaired growth and neurodevelopment. The fatty acid contents of parenteral and enteral nutrition are insufficient to meet current recommendations. This chapter summarizes the regulatory roles of fatty acids, current recommendations and limitations of parenteral and enteral nutrition in meeting these recommendations in preterm infants. Suggested areas for research on the roles of fatty acids in preterm infant health are also provided.
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21
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Shulhan J, Dicken B, Hartling L, Larsen BM. Current Knowledge of Necrotizing Enterocolitis in Preterm Infants and the Impact of Different Types of Enteral Nutrition Products. Adv Nutr 2017; 8:80-91. [PMID: 28096129 PMCID: PMC5227976 DOI: 10.3945/an.116.013193] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Preterm infants are extremely vulnerable to a range of morbidities and mortality. Underdeveloped cardiac, respiratory, gastrointestinal, and immune systems in the preterm period increase the risk of necrotizing enterocolitis (NEC), a serious disease of the gut. NEC affects 5-12% of very-low birth-weight infants, leads to surgery in 20-40% of cases, and is fatal in 25-50% of cases. There are multiple factors that may contribute to NEC, but the exact cause is not yet fully understood. Severe cases can result in intestinal resection or death, and the health care costs average >$300,000/infant when surgical management is required. Different types of nutrition may affect the onset or progression of NEC. Several studies have indicated that bovine milk-based infant formulas lead to a higher incidence of NEC in preterm infants than does human milk (HM). However, it is not clear why HM is linked to a lower incidence of NEC or why some infants fed an exclusively HM diet still develop NEC. An area that has not been thoroughly explored is the use of semielemental or elemental formulas. These specialty formulas are easy to digest and absorb in the gut and may be an effective nutritional intervention for reducing the risk of NEC. This review summarizes what is known about the factors that contribute to the onset and progression of NEC, discusses its health care cost implications, and explores the impact that different formulas and HM have on this disease.
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Affiliation(s)
- Jocelyn Shulhan
- Departments of Pediatrics and
- Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, Canada
| | - Bryan Dicken
- Surgery, Faculty of Medicine and Dentistry, and
- Stollery Children's Hospital, Edmonton, Canada; and
| | - Lisa Hartling
- Departments of Pediatrics and
- Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, Canada
| | - Bodil Mk Larsen
- Departments of Pediatrics and
- Stollery Children's Hospital, Edmonton, Canada; and
- Nutrition Services, Alberta Health Services, Edmonton, Canada
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22
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Dritsakou K, Liosis G, Valsami G, Polychronopoulos E, Skouroliakou M. The impact of maternal- and neonatal-associated factors on human milk's macronutrients and energy. J Matern Fetal Neonatal Med 2016; 30:1302-1308. [PMID: 27405688 DOI: 10.1080/14767058.2016.1212329] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To test the impact of specific maternal- and neonatal-associated factors on human milk's macronutrients and energy. METHODS This study was conducted with the use of a human milk analyzer (HMA, MIRIS, Uppsala, Sweden). Six hundred and thirty samples of raw milk and 95 samples of donor pasteurized milk were delivered from a total of 305 mothers. RESULTS A significant inverse correlation of fat, protein and energy content with gestational age and birth weight was established. Fat and energy were lower in colostrum, increased in transitional milk and decreased on the 30th day's mature milk compared to transitional. The rate of protein decline from colostrum to mature milk was lower in premature deliveries compared to that of full-terms, resulting in greater contents of protein in preterm mature milk. The upmost amounts of carbohydrates were found in mature milk of preterm deliveries. A positive correlation was found between maternal age and fat contents. In women with higher post-pregnancy BMI levels greater analogies of fat and energy were presented. In women suffering diet-controlled gestational diabetes (GD), lower protein and higher fat and energy levels were found. CONCLUSIONS Prematurity, maternal age, diet-controlled GD and high post-pregnancy BMI levels were found to impose statistical significant effect on milk's macronutrients and energy.
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Affiliation(s)
- Kalliopi Dritsakou
- a Department of Quality Control , Research and Continuing Education, Elena Venizelou Maternity Hospital , Athens , Greece
| | - Georgios Liosis
- b Human Donor Milk Bank, NICU, Elena Venizelou Maternity Hospital , Athens , Greece
| | - Georgia Valsami
- c School of Pharmacy, University of Athens , Athens , Greece
| | - Evangelos Polychronopoulos
- d Department of Science of Dietetics - Nutrition , Harokopeion University of Athens , Athens , Greece , and
| | - Maria Skouroliakou
- e Department of Science of Dietetics- Nutrition , Harokopeion University of Athens , Athens , Greece
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23
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Stoltz Sjöström E, Lundgren P, Öhlund I, Holmström G, Hellström A, Domellöf M. Low energy intake during the first 4 weeks of life increases the risk for severe retinopathy of prematurity in extremely preterm infants. Arch Dis Child Fetal Neonatal Ed 2016; 101:F108-13. [PMID: 25678632 PMCID: PMC4789715 DOI: 10.1136/archdischild-2014-306816] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 01/10/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Poor weight gain during the first weeks of life in preterm infants is closely associated with the risk of developing the retinopathy of prematurity (ROP) and insufficient nutrition might be an important contributing factor. This study aimed to evaluate the effect of energy and macronutrient intakes during the first 4 weeks of life on the risk for severe ROP (stages 3-5). STUDY DESIGN A population-based study including all Swedish extremely preterm infants born before 27 gestational weeks during a 3-year period. Each infant was classified according to the maximum stage of ROP in either eye as assessed prospectively until full retinal vascularisation. The detailed daily data of actual intakes of enteral and parenteral nutrition and growth data were obtained from hospital records. RESULTS Of the included 498 infants, 172 (34.5%) had severe ROP and 96 (19.3%) were treated. Energy and macronutrient intakes were less than recommended and the infants showed severe postnatal growth failure. Higher intakes of energy, fat and carbohydrates, but not protein, were significantly associated with a lower risk of severe ROP. Adjusting for morbidity, an increased energy intake of 10 kcal/kg/day was associated with a 24% decrease in severe ROP. CONCLUSIONS We showed that low energy intake during the first 4 weeks of life was an independent risk factor for severe ROP. This implies that the provision of adequate energy from parenteral and enteral sources during the first 4 weeks of life may be an effective method for reducing the risk of severe ROP in extremely preterm infants.
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Affiliation(s)
| | - Pia Lundgren
- Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Inger Öhlund
- Department of Clinical Sciences, Paediatrics, Umeå University, Umeå, Sweden
| | - Gerd Holmström
- Department of Neuroscience, Ophthalmology, Uppsala University, Uppsala, Sweden
| | - Ann Hellström
- Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Magnus Domellöf
- Department of Clinical Sciences, Paediatrics, Umeå University, Umeå, Sweden
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Abstract
PURPOSE OF REVIEW To outline new evidence published from 2013 to 2014 about breast milk fortification in preterm infants. RECENT FINDINGS Breast milk is the feeding choice for preterm infants because of its immunoprotective properties. However, breast milk's nutrient content is not sufficient for preterm infants, and interindividual variation is high. The variation challenges standard fortification, which assumes a standard breast milk composition. Two new fortification strategies (adjustable fortification and target fortification) optimize macronutrient intake and improve growth. Adjustable fortification uses blood urea nitrogen levels to adjust fortifier strength. Target fortification analyzes breast milk and fortifies macronutrients individually to achieve targeted intake. Its feasibility is shown in clinical routine. Current breast milk analyzers used for target fortification achieve acceptable precision for protein and fat but not for lactose and energy. Evidence of benefits for postdischarge breast milk fortification is lacking. Eliminating cow's milk products and feeding exclusively breast milk may decrease the occurrence of feeding intolerance and necrotizing enterocolitis. To facilitate exclusively breast milk diets, a collaboration of prenatal, nutrition and lactation stakeholders is key. Fortification increases osmolality; however, safety cutoffs to prevent necrotizing enterocolitis are unclear. There is also new evidence that composition and structure of various macronutrients and micronutrients affect growth and development, and might play a role in future fortification concepts. SUMMARY Recent research focuses on the variability of breast milk composition, its impact on postnatal growth patterns and the usefulness of target fortification. As well, diets exclusively composed of human milk are a promising approach to improve feeding tolerance. For safe fortification, osmolality cutoff levels are needed.
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Affiliation(s)
- Niels Rochow
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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