Nutrient enrichment of mother's milk and growth of very preterm infants after hospital discharge

Growth at 2 years corrected age in preterm infants discharged on two different breast milk enhancements: An observational study

OBJECTIVE

Breast milk (BM) enhancement is often used to meet the nutritional needs of preterm infants after hospital discharge to achieve optimal growth. This study compared growth at 18-28 months corrected age (CA) among very preterm (VP) and very low birth weight (VLBW) infants discharged from the neonatal intensive care units (NICUs) on two BM enhancements.

METHODS

We conducted a retrospective chart review study of infants born between January 1, 2013 and December 31, 2017, with gestational age < 32 weeks or birthweight < 1500 g, discharged from the NICU on BM enhancements; fortification of BM with infant formula additives (BM-F) or unfortified BM supplemented with bottle feeds of infant formula (BM-S). BM enhancements were nonrandomized and determined by the medical team. A linear mixed model regression analysis with propensity score matching was used to estimate the adjusted associations between the nutrition plan at discharge and growth outcomes at 18-28 months CA follow-up.

RESULTS

Two hundred and fifty-one VLBW/VP infants were included. Compared with BM-S, infants discharged on BM-F were more likely to continue receiving BM at 8-12 months CA, and had lower head circumference, weight-for-length z scores, and higher incidence of moderate malnutrition (p ≤ 0.01). After adjusting for confounders, discharge on BM-F was associated with a lower incidence of overweight/obesity at 18-28 months CA (odds interval: 0.45; confidence interval: 0.21-0.96; p = 0.04).

CONCLUSIONS

This retrospective study suggests that VLBW/VP infants discharged on BM-F received BM longer, had lower growth parameter and were less likely to be overweight/obese at 18-28 months CA. Further studies are needed to evaluate the role of postdischarge nutrition on preterm born children's growth, metabolic disease, and neurodevelopmental outcomes.

Is an Exclusive Human Milk Diet at the Time of Neonatal Intensive Care Unit Discharge Adequate to Maintain Growth and Neurodevelopment among Very Preterm Infants?

Background: An exclusive human milk (EHM) diet has numerous benefits. Formula supplementation may be recommended for former preterm infants at the time of neonatal intensive care unit (NICU) discharge to meet perceived metabolic demands and caloric goals. Recommendations addressing postdischarge nutrition for very preterm infants (VPTIs) are controversial, as the benefits of human milk supplementation regarding long-term growth, neurodevelopment, and chronic conditions are mixed. Objective: To compare growth and neurodevelopment of former VPTI fed an EHM diet to a supplemented/formula diet at NICU discharge. Materials and Methods: A retrospective cohort study of VPTI was followed at the Regional Neonatal Follow-up Program. Patients were categorized by diet at NICU discharge: EHM diet; mixed diet (EHM and formula); and exclusive formula diet. Growth percentile ranks at the first neonatal follow-up visit and 3 years of age were compared by diet type at NICU discharge. Neurodevelopmental outcomes as measured by the Bayley Scales of Infant Development 3rd Edition at 3 years of age were also compared. Results: Among 835 VPTIs, weight percentiles at the first neonatal follow-up visit were similar between the three NICU discharge diet types. One hundred fifty-eight subjects received neurodevelopmental evaluations at 3 years of age; anthropometrics and neurodevelopment were similar irrespective of diet at NICU discharge. Conclusion: An EHM diet at NICU discharge is appropriate to support growth in infancy as well as growth and neurodevelopment through 3 years of age. Thus, this raises the question of whether routine nutritional supplementation is necessary for VPTIs at NICU discharge.

The ASQ did not predict low IQ scores when children born VPT were six years

AIM

There is a need for methods that can provide valid assessment tools in a follow-up programme without great financial costs. This study assessed the accuracy of the 60-month Ages and Stages Questionnaire as a screening tool to predict a low intelligence quotient score at 6 years in children born very preterm.

METHODS

Totally, 54 children participated in a six-year follow-up study, which included an intelligence quotient test at 6 years of age and a 60-month Ages and Stages Questionnaire at four and a half or 5 years of age at respond. We used the receiver operating characteristic curve and evaluated the optimal cut-off score to predict a low intelligence quotient score.

RESULTS

At four and a half years, the optimal cut-off value for predicting a low intelligence quotient score was 242, with a sensitivity of 67% and a specificity of 59%. At 5 years, only one child had a low intelligence quotient score, and the analysis was not performed.

CONCLUSION

Our results did not support the use of the 60-month Ages and Stages Questionnaire as a valuable screening tool to predict a low intelligence quotient score in children born very preterm at 6 years of age.

Human Milk Fortifier After Neonatal Intensive Care Unit Discharge Improves Human Milk Usage Rates for Preterm Infants

BACKGROUND

A common neonatal intensive care unit (NICU) discharge feeding strategy for preterm infants with growth failure who are fed exclusively expressed human milk (EHM) has been to enrich mother's own milk with formula powder or supplement 2-3 feeds per day with formula. However, this strategy displaces human milk from the diet. Our NICU recently adopted the standard practice of adding commercial human milk fortifier (HMF) to human milk feedings after discharge.

OBJECTIVES

We aimed to compare breastfeeding rates and growth using the aforementioned 2 strategies.

METHODS

Preterm infants (<34 wk of gestation at birth) exclusively feeding EHM fortified with HMF at 2 weeks before discharge were included in this retrospective study. The HMF group (n = 92) continued fortifying with HMF at home, whereas the historical comparison group (n = 35) received our previous guidance to enrich or supplement using postdischarge formula.

RESULTS

Rates of human milk exclusivity after discharge decreased significantly less in the HMF group than those in the historical comparison group (to 83% compared with 39% at the first outpatient visit and 27% compared with 6%, respectively, at the second outpatient visit). Rates of any EHM feedings were also significantly higher in the HMF group. Fenton z-scores for weight, length, and head circumference were not significantly different between the groups.

CONCLUSIONS

Continuing EHM fortification with HMF after NICU discharge, rather than enriching or supplementing with postdischarge infant formula, increases rates of feeding EHM for ≥3 mo but does not affect growth.

Nutrition Management of High-Risk Neonates After Discharge

Nutrition management of the high-risk infant after hospital discharge is complicated by the infant's dysfunctional or immature oral feeding skills, nutritional deficits, and the family's feeding plan. Although evidence is limited, available studies point to developing an individualized nutritional plan, which accounts for these factors; protects and prioritizes the family's plan for breastfeeding; and promotes an acceptable growth pattern. Further research is needed to identify the type and duration of posthospital discharge nutrition to optimize high-risk infant neurodevelopment and body composition. Attention to infant growth, lactation support, and safe feed preparation practices are critical in the transition to home.

Postdischarge Nutrition in Preterm Infants

The field of postdischarge nutrition for preterm infants arose when concerns that using diets suitable for term infants-breastfeeding without fortification or standard formulas-might not meet the postdischarge nutritional needs of infants born preterm, who often exhibited growth restriction and evidence of undernutrition. A decade ago, there were already 27 randomized controlled trials (RCTs) of nutritional supplementation from which an eligible subsample of trials have provided evidence on whether nutritional fortification of human milk or nutrient-enriched formula favorably affects postdischarge growth in these infants. These RCTs also allowed exploration of the quality of growth, bone mineralization, and the ad libitum-fed infant's own regulation of milk volume and nutrient intake. Importantly, such RCTs, augmented by observational data on the links between growth and neurodevelopment, have allowed exploration of the potential impact of postdischarge nutrition on neurocognitive function. However, the interpretation of published data and the implication for practice has proven difficult and contentious. In this review, we examine, and to an extent reanalyze, existing evidence to elucidate its strengths and limitations, with the goal of adding more clarity to the ways in which this sizeable body of clinical scientific research may have a positive impact on the postdischarge nutritional approach to infants born preterm.

IQ Was Not Improved by Post-Discharge Fortification of Breastmilk in Very Preterm Infants

(1) Very preterm infants are at increased risk of cognitive deficits, motor impairments, and behavioural problems. Studies have tied insufficient nutrition and growth to an increased risk of neurodevelopmental impairment; (2) Methods: Follow-up study on cognitive and neuropsychological development at 6 years corrected age (CA) in 214 very preterm infants, including 141 breastfed infants randomised to mother’s own milk (MOM) with (F-MOM) or without (U-MOM) fortification and 73 infants fed a preterm formula (PF-group), from shortly before discharge to 4 months CA. Infants with serious congenital anomalies or major neonatal morbidities were excluded prior to intervention. The Wechsler Intelligence Scale for Children IV was used for cognitive testing, and the children’s parents completed the Five to Fifteen Questionnaire (FTF); (3) Results: Post-discharge fortification of MOM did not improve either full-scale intelligence quotient (FSIQ) with a median of 104 vs. 105.5 (p = 0.29), subdomain scores, or any domain score on the FTF questionnaire. Compared to the PF group, the MOM group had significantly better verbal comprehension score with a median of 110 vs. 106 (p = 0.03) and significantly better motor skills scores on the FTF questionnaire (p = 0.01); (4) Conclusions: The study supports breastfeeding without fortification as post-discharge nutrition in very preterm infants, and it seems superior to preterm formula.

State of the evidence from clinical trials on human milk fortification for preterm infants

Infants born preterm or low birth weight are at risk for morbidity, mortality and later neuroimpairment. Appropriate early post-natal growth is associated with better outcomes in-hospital and post-discharge. Therefore, nutritional strategies that support growth may improve the long-term health of this population. Mother's milk with donor milk as a supplement are preferred sources of nutrition for these infants but may not always support growth, especially amongst infants born of very low birth weight (<1500 g) and or those with a major morbidity. Systematic reviews of randomised controlled trials to date demonstrate that multi-nutrient fortification of human milk improves in-hospital growth of preterm infants although data on long-term neurodevelopment are lacking. Further, individualised approaches to fortification based on milk analysis or the infant's metabolic response may improve growth over standard fortification. The evidence is insufficient to inform the timing of introducing fortifier, routine fortification of feeds post-discharge or routine use of fortifiers made from human instead of bovine milk. Importantly, there is insufficient data to determine if these fortification practices improve relevant clinical or neurodevelopmental outcomes. In sum, there is an urgent need for well-designed clinical trials to assess potential benefits and risks of fortification practices and at what cost.

Redesigning care to support earlier discharge from a neonatal intensive care unit: a design thinking informed pilot

Background

Preterm infants may remain in neonatal intensive care units (NICUs) to receive proper nutrition via nasogastric tube feedings. However, prolonged NICU stays can have negative effects for the patient, the family and the health system.

Aim

To demonstrate how a patient-centred, design thinking informed approach supported the development of a pilot programme to enable earlier discharge of preterm babies.

Method

We report on our design thinking-empathy building approach to programme design, initial outcomes and considerations for ongoing study.

Results

Through the use of design thinking methods, we identified unique needs, preferences and concerns that guided the development of our novel early discharge programme. We found that stable, preterm infants unable to feed by mouth and requiring nasogastric tubes can be cared for at home with remote patient monitoring and telehealth support. In addition, novel feeding strategies can help address parental preferences without compromising infant growth.

Conclusion

A patient-centred, design thinking informed approach supported the development of a pilot programme to enable earlier discharge of preterm babies. The programme resulted in a reduced length of stay, thereby increasing NICU bed capacity and limiting hospital turn-aways.

Evidence-based Discharge Nutrition to Optimize Preterm Infant Outcomes

Despite abundant research comparing postdischarge hospital diets for preterm infants, the ideal clinical approach has not been determined. Dilemmas persist because randomized controlled trials of preterm versus term infant formula have yielded equivocal results and because the predominant postdischarge diet for preterm infants has shifted from formula-based to a combination that includes maternal milk and increasingly includes a plan for breastfeeding. As the investigation of the influence of the post-hospital discharge diet on preterm infant outcomes evolves, factors to consider include the infant's oral feeding ability and the maternal lactation goal. The maturation of the preterm infant's oral feeding skills may at least partially explain why increased nutrient density appears to most benefit growth outcomes when given during the first 3 to 4 months after hospital discharge. At some point in maturation, the preterm infant may develop the ability to vary intake as needed to obtain sufficient nutrition no matter the density of the diet. In addition, attention to the maternal lactation goal is critical as intake of maternal milk likely influences neurodevelopmental outcomes as much or even to a greater extent than growth trajectory.

Sex-Specific Effects of Nutritional Supplements for Infants Born Early or Small: An Individual Participant Data Meta-Analysis (ESSENCE IPD-MA) I-Cognitive Function and Metabolic Risk

Neonatal nutritional supplements are widely used to improve growth and development but may increase risk of later metabolic disease, and effects may differ by sex. We assessed effects of supplements on later development and metabolism. We searched databases and clinical trials registers up to April 2019. Participant-level data from randomised trials were included if the intention was to increase macronutrient intake to improve growth or development of infants born preterm or small-for-gestational-age. Co-primary outcomes were cognitive impairment and metabolic risk. Supplementation did not alter cognitive impairment in toddlers (13 trials, n = 1410; adjusted relative risk (aRR) 0.88 [95% CI 0.68, 1.13]; p = 0.31) or older ages, nor alter metabolic risk beyond 3 years (5 trials, n = 438; aRR 0.94 [0.76, 1.17]; p = 0.59). However, supplementation reduced motor impairment in toddlers (13 trials, n = 1406; aRR 0.76 [0.60, 0.97]; p = 0.03), and improved motor scores overall (13 trials, n = 1406; adjusted mean difference 1.57 [0.14, 2.99]; p = 0.03) and in girls not boys (p = 0.03 for interaction). Supplementation lowered triglyceride concentrations but did not affect other metabolic outcomes (high-density and low-density lipoproteins, cholesterol, fasting glucose, blood pressure, body mass index). Macronutrient supplementation for infants born small may not alter later cognitive function or metabolic risk, but may improve early motor function, especially for girls.

Macronutrient analysis of human milk and factors associated with its composition in mothers of preterm infants ≤ 32 weeks

We conducted an exploratory longitudinal study to evaluate the macronutrient composition of human milk in mothers delivering very preterm infants ≤ 32 weeks over the first 4 weeks of lactation and the association of human milk composition with maternal and neonatal factors A total of 213 human milk samples collected in the morning between 8 am and 12 pm from 60 eligible mothers were analyzed on 7 (n = 60), 14 (n = 60), 21 (n = 52), and 28 (n = 41) days of lactation by infrared transmission spectroscopy. The true protein content decreased significantly over 4 weeks (mean difference (95% confidence interval)) (MD (95% CI)) week 1 and week 4 = 0.2 g (0.037 to 0.363, P = 0.009)). On the contrary, the mean fat and calorie content showed significant increase over time (MD (95% CI)) = - 1.03 g (- 1.719 to - 0.343, P = 0.001) and - 9.0 kcal/dl (- 15.170 to - 2.830, P = 0.001), respectively). There was no difference in the carbohydrate content of human milk over 4 weeks. Macronutrient composition was independent of maternal parity, mode of delivery, pre-pregnancy body mass index, umbilical artery Doppler flows, previous breast feeding experience, neonatal centile status, gestation, and infant's weight at birth. Multiple regression analysis of human milk composition with mother's dietary components showed no significant association. CONCLUSION : We conclude that in mothers who deliver very preterm infants ≤ 32 weeks, true protein content decreased, fat and calorie content increased, and carbohydrate content remained stable in human milk during first 4 weeks of lactation. Human milk macronutrient composition was independent of various maternal and neonatal factors including maternal body mass index and dietary intake. TRIAL REGISTRATION : CTRI/2017/02/007895 What is Known: • Preterm human milk has high temporal and inter-individual variation in the macronutrient composition. What is New: • In mothers who deliver very preterm infants < 32 weeks, true protein content decreases, fat and calorie content increases, and carbohydrate content remains stable in human milk during first 4 weeks of lactation. • Human milk macronutrient composition is independent of various maternal and neonatal factors including maternal body mass index and dietary intake.

Stoma Closure Improves Head Circumference Growth in Very Preterm Infants after Necrotizing Enterocolitis

INTRODUCTION

 Very preterm infants (VPIs) surgically treated for necrotizing enterocolitis (NEC) are at risk of growth retardation. The aim of this study was to demonstrate and compare growth during the first 6 years of life in VPIs with stoma after NEC surgery with VPIs without NEC surgery.

MATERIALS AND METHODS

 We included all VPIs surgically treated due to NEC at the Odense University Hospital from August 1, 2004, to July 31, 2008. Outcome on growth was compared with a group of VPIs without NEC. The VPIs with NEC were identified searching the local database using the International Classification of Diseases, 10th Revision diagnosis of NEC (DP77.9). Data on growth were collected from medical files and if not present, the parents reported the data.

RESULTS

 Nineteen VPIs, surgically treated due to NEC, survived to 6 years of age. Median gestational age was 28^3/7 weeks (24^5/7-31^3/7). Median age at NEC surgery and stoma formation was 2.3 weeks (0.1-6.3) and median age at stoma closure was 2.5 months corrected age (CA) (postmenstrual age 36 weeks to CA 6.7 months). Compared with the non-NEC group, VPIs with NEC and stoma demonstrated poor growth, especially in head circumference (HC) with no increase in growth velocity before the time of stoma closure between 2.5- and 3-month CAs.

CONCLUSION

 Our findings demonstrate poor growth in VPIs after NEC surgery and improved HC growth after stoma closure.

Using Nature to Nurture: Breast Milk Analysis and Fortification to Improve Growth and Neurodevelopmental Outcomes in Preterm Infants

Premature infants are born prior to a critical window of rapid placental nutrient transfer and fetal growth-particularly brain development-that occurs during the third trimester of pregnancy. Subsequently, a large proportion of preterm neonates experience extrauterine growth failure and associated neurodevelopmental impairments. Human milk (maternal or donor breast milk) is the recommended source of enteral nutrition for preterm infants, but requires additional fortification of macronutrient, micronutrient, and energy content to meet the nutritional demands of the preterm infant in attempts at replicating in utero nutrient accretion and growth rates. Traditional standardized fortification practices that add a fixed amount of multicomponent fortifier based on assumed breast milk composition do not take into account the considerable variations in breast milk content or individual neonatal metabolism. Emerging methods of individualized fortification-including targeted and adjusted fortification-show promise in improving postnatal growth and neurodevelopmental outcomes in preterm infants.

Promoting Human Milk and Breastfeeding for the Very Low Birth Weight Infant

Provision of mother's own milk for hospitalized very low birth weight (VLBW) (≤1500 g) infants in the NICU provides short- and long-term health benefits. Mother's own milk, appropriately fortified, is the optimal nutrition source for VLBW infants. Every mother should receive information about the critical importance of mother's own milk to the health of a VLBW infant. Pasteurized human donor milk is recommended when mother's own milk is not available or sufficient. Neonatal health care providers can support lactation in the NICU and potentially reduce disparities in the provision of mother's own milk by providing institutional supports for early and frequent milk expression and by promoting skin-to-skin contact and direct breastfeeding, when appropriate. Promotion of human milk and breastfeeding for VLBW infants requires multidisciplinary and system-wide adoption of lactation support practices.

Discharge of Medically Complex Infants and Developmental Follow-up

At the time of discharge from the NICU, many infants have ongoing complex medical issues that will require coordinated, multispecialty follow-up. Discharge planning and transfer of care for infants with medical complexity require a multidisciplinary team effort that begins early during the NICU hospitalization. It is critical that the primary care physician is involved in this process because he or she will serve as the chief communicator and coordinator of care after discharge. Although some infants with medical complexity may be followed in specialized multidisciplinary NICU follow-up clinics, these are not universally available. The responsibility then falls to the primary care physician to coordinate with different subspecialties based on the infant's needs. Many infants with medical complexity are technology-dependent at the time of discharge and may require home oxygen, ventilators, monitors, or tube feeding. Prematurity, critical illness, and prolonged NICU hospitalization that lead to medical complexity also increase the risk of neurodevelopmental delay or impairment. As such, these infants will not only require routine developmental surveillance and screening by the primary care physician but also should be followed longitudinally by a neurodevelopmental specialist, either a developmental-behavioral pediatrician or a neonatologist with experience in neurodevelopmental assessment.

The role of breast milk fortifier in the post-discharge nutrition of preterm infants

Infants born prematurely are often discharged from hospital before 37 weeks post-menstrual age. While breastfeeding will meet all the nutritional requirements of full-term infants, these preterm infants may need enhanced levels of protein, minerals and possibly energy to ensure optimum growth, bone mineralisation and neurological development. To meet these additional nutrient needs in the neonatal unit, it is currently recommended that multinutrient breast milk fortifier is added to maternal breast milk. There may also be benefits in continuing to provide fortified milk after discharge, potentially including improved growth and preserving breastfeeding, and this is increasingly becoming a recognised practice in some neonatal units. This article presents the discussion and consensus of a multidisciplinary panel of neonatologists, neonatal dietitians, a GP and a neonatal outreach sister. The aim is to develop guidance on providing safe and effective nutritional supplementation for preterm infants after discharge in order to maintain optimal growth. This guidance is aimed at community healthcare staff and is based on the limited evidence available, using shared best practice and expertise.

The use of Breast Milk Fortifier in Preterm Infants by paediatric dietitians in the UK

BACKGROUND

Breast milk is the feed of choice for premature infants, although its nutritional composition is not always sufficient to meet their raised nutritional requirements. The addition of a multi-nutrient breast milk fortifier (BMF) to breastmilk is recommended; however, international guidelines on the use of BMF are inconsistent. The present study aimed to explore the use of BMF in preterm infants by paediatric dietitians in the UK.

METHODS

A questionnaire was designed and sent to members of the British Dietetic Association neonatal specialist group (n = 100) using a secure online platform. Descriptive statistics were calculated.

RESULTS

Forty dietitians completed the survey, all of whom used BMF. Local hospital BMF guidelines were available to 77.5% (n = 31). The most commonly used criteria for commencing BMF were: tolerating a feed volume of 150 mL kg^-1  day^-1 (72.5%, n = 29), a gestational age <34 weeks (67.5%, n = 27) and a birth weight <1500 g (60%, n = 24). The primary contraindication for the use of BMF was necrotising enterocolitis (NEC). The majority of respondents used standard fortification, with individualised fortification available to only 12.5% (n = 5). The most common indicators for discontinuing BMF were on discharge home (67.5%, n = 27), satisfactory growth (65%, n = 26) or feeding directly from the breast (62.5%, n = 25).

CONCLUSIONS

Although BMF is used more proactively in UK neonatal units than previously, variation in practice remains. Individualised fortification is very uncommon and caution remains regarding risk of NEC. The development of national guidelines on the use of BMF would help to standardise nutritional care in neonatal units.

Comparison of Types of Breast Milk Fortification at Discharge from the Neonatal Intensive Care Unit and Breast Milk Feeding Rates and Growth at 4 Months Corrected Age

Background: Effects of breast milk (BM) enhancement on long-term BM feeding in preterm infants discharged from the neonatal intensive care unit (NICU) have not been examined previously. This study compares any BM feeding rates at 4 months corrected age (CA) in preterm infants discharged from the NICU on BM enhancement by fortification of expressed BM with infant formula additives (BM-F) versus BM supplemented with infant formula feeds (BM-S). Subjects and Methods: We compared infants born between January 1, 2013, and December 31, 2017, with gestational age <32 weeks or birth weight <1500 g, discharged home on BM-F or BM-S from two NICUs and followed at 4 months CA. Multivariate logistic regression with propensity scoring estimated the adjusted associations between nutrition at discharge and any BM feeding at 4 months CA. Results: Two hundred eighty-five infants were followed at 4 months CA. Infants discharged on BM-F were more likely to have mothers with multiple gestation, private insurance and not Caucasian, initiate feeds of human milk, be discharged from NICU-1, and receive any BM at 4 months CA (p < 0.03). No significant difference in growth parameters <10th percentile at 4 months CA was observed between the two groups. After adjusting for confounding factors, discharge from the NICU on BM-F was significantly associated with BM feeding at 4 months CA (odds ratio: 3.89, 95% confidence interval 1.66-9.14, p = 0.002). Conclusion: In this observational study, preterm infants receiving BM fortified with formula powder additives at discharge from the NICU had better BM feeding outcomes without poor growth at 4 months CA relative to those infants receiving BM supplemented with infant formula feeds.

Impact of macronutrient supplements on later growth of children born preterm or small for gestational age: A systematic review and meta-analysis of randomised and quasirandomised controlled trials

BACKGROUND

Nutritional supplements may improve short-term growth of infants born small (preterm or small for gestational age), but there are few data on long-term effects and concerns that body composition may be adversely affected. Effects also may differ between girls and boys. Our systematic review and meta-analysis assessed the effects of macronutrient supplements for infants born small on later growth.

METHODS AND FINDINGS

We searched OvidMedline, Embase, Cochrane CENTRAL, and Cochrane Database of Systematic Reviews from inception to January 30, 2020, and controlled-trials.com, clinicaltrials.gov, and anzctr.org.au on January 30, 2020. Randomised or quasirandomised trials were included if the intention was to increase macronutrient intake to improve growth or development of infants born small and growth was assessed after discharge. Primary outcome was body mass index (BMI) in childhood. Data were pooled using random-effect models. Outcomes were evaluated in toddlers (< 3 years), childhood (3 to 8 years), adolescence (9 to 18 years), and adulthood (>18 years). Forty randomised and 2 quasirandomised trials of variable methodological quality with 4,352 infants were included. Supplementation did not alter BMI in childhood (7 trials, 1,136 children; mean difference [MD] -0.10 kg/m2, [95% confidence interval (CI) -0.37 to 0.16], p = 0.45). In toddlers, supplementation increased weight (31 trials, 2,924 toddlers; MD 0.16 kg, [0.01 to 0.30], p = 0.03) and length/height (30 trials, 2,889 toddlers; MD 0.44 cm, [0.10 to 0.77], p = 0.01), but not head circumference (29 trials, 2,797 toddlers; MD 0.15 cm, [-0.03 to 0.33], p = 0.10). In childhood, there were no significant differences between groups in height (7 trials, 1,136 children; MD 0.22 cm, [-0.48 to 0.92], p = 0.54) or lean mass (3 trials, 354 children; MD -0.07 kg, [-0.98 to 0.85], p = 0.88), although supplemented children appeared to have higher fat mass (2 trials, 201 children; MD 0.79 kg, [0.19 to 1.38], p = 0.01). In adolescence, there were no significant differences between groups in BMI (2 trials, 216 adolescents; MD -0.48 kg/m2, [-2.05 to 1.08], p = 0.60), height (2 trials, 216 adolescents; MD -0.55 cm, [-2.95 to 1.86], p = 0.65), or fat mass (2 trials, 216 adolescents; MD -1.3 5 kg, [-5.76 to 3.06], p = 0.55). In adulthood, there also were no significant differences between groups in weight z-score (2 trials, 199 adults; MD -0.11, [-0.72 to 0.50], p = 0.73) and height z-score (2 trials, 199 adults; MD -0.07, [-0.36 to 0.22], p = 0.62). In subgroup analysis, supplementation was associated with increased length/height in toddler boys (2 trials, 173 boys; MD 1.66 cm, [0.75 to 2.58], p = 0.0003), but not girls (2 trials, 159 girls; MD 0.15 cm, [-0.71 to 1.01], p = 0.74). Limitations include considerable unexplained heterogeneity, low to very low quality of evidence, and possible bias due to low or unbalanced followup.

CONCLUSIONS

In this systematic review and meta-analysis, we found no evidence that early macronutrient supplementation for infants born small altered BMI in childhood. Although supplements appeared to increase weight and length in toddlers, effects were inconsistent and unlikely to be clinically significant. Limited data suggested that supplementation increased fat mass in childhood, but these effects did not persist in later life. PROSPERO registration: CRD42019126918.

Impact of macronutrient supplements for children born preterm or small for gestational age on developmental and metabolic outcomes: A systematic review and meta-analysis

BACKGROUND

Nutritional supplements may improve development of infants born small (preterm or small for gestational age [SGA]) but may increase the risk of later metabolic disease. We conducted a systematic review and meta-analysis to assess the effects of macronutrient supplements for infants born small on later development and metabolism.

METHODS AND FINDINGS

We searched OvidMedline, Embase, Cochrane CENTRAL, and Cochrane Database of Systematic Reviews from inception to April 1, 2019, and controlled-trials.com, clinicaltrials.gov, and anzctr.org.au. Randomised or quasirandomised trials were included if the intention was to increase macronutrient intake to improve growth or development of infants born small and assessed post-discharge outcomes. Co-primary outcomes were cognitive impairment and metabolic risk, evaluated in toddlers (<3 years), childhood (3 to 8 years), and adolescence (9 to 18 years). Two reviewers independently extracted data. Quality was assessed using the Cochrane Risk of Bias tool, and data were pooled using random-effect models. Twenty-one randomised and one quasirandomised trial of variable methodological quality involving 3,680 infants were included. In toddlers born small, supplementation did not alter cognitive impairment (relative risk [RR] 1.00; 95% confidence interval [CI] 0.67 to 1.49; P = 0.99), and there were no differences in cognitive scores (mean difference [MD] 0.57; 95% CI -0.71 to 1.84; P = 0.38) or motor scores (MD 1.16; 95% CI -0.32 to 2.65; P = 0.12) between supplemented and unsupplemented groups. However, fewer supplemented children had motor impairment (RR 0.76; 95% CI 0.62 to 0.94; P = 0.01). In subgroup analyses, supplementation improved cognitive scores in boys (MD 5.60; 95% CI 1.07 to 10.14; P = 0.02), but not girls born small (MD -2.04; 95% CI -7.04 to 2.95; P = 0.42), and did not alter cognitive or motor scores in the subgroup of children born SGA. In childhood, there was no difference in cognitive impairment (RR 0.81; 95% CI 0.26 to 2.57; P = 0.72) or cognitive scores (MD 1.02; 95% CI -1.91 to 3.95; P = 0.50) between supplemented and unsupplemented groups. There were also no differences in blood pressure, triglyceride, and low-density lipoprotein (LDL) concentrations (all P > 0.05). However, supplemented children had lower fasting glucose (mmol/L: MD -0.20; 95% CI -0.34 to -0.06; P = 0.005) and higher high-density lipoprotein (HDL) concentrations (mmol/L: MD 0.11; 95% CI 0.02 to 0.19; P = 0.02). In subgroup analyses, there was no evidence of differences in blood pressure between supplemented and unsupplemented groups in boys or girls born small, or in SGA children. In adolescence, there was no difference between supplemented and unsupplemented groups in blood pressure, triglycerides, LDL and HDL concentrations, fasting blood glucose, insulin resistance, and fasting insulin concentrations (all P > 0.05). Limitations include considerable unexplained heterogeneity, low to very low quality of the evidence, and limited data beyond early childhood.

CONCLUSIONS

In this systematic review and meta-analysis of randomised trials, we found no evidence that early macronutrient supplementation for infants born small altered later cognitive function, although there was some evidence that supplementation may decrease motor impairment in toddlers. Contrary to the findings from observational studies, evidence from randomised trials suggests that early macronutrient supplementation for infants born small improves some metabolic outcomes in childhood.

PROSPERO REGISTRATION

CRD42019127858.

Factors affecting the catch-up growth of preterm infants after discharge in China: a multicenter study based on the health belief model

BACKGROUND

The purpose of this study was to analyze the growth status and to identify the risk factors that influence the catch-up growth of preterm infants after discharge and to provide evidence for feeding strategies and the need for further research.

METHODS

A descriptive correlational analysis was applied. The sample consisted of 309 preterm infants and their caregivers selected from June to August 2017 from five women's and children's hospitals. Self-designed questionnaires based on knowledge, attitude and practice and the Health Belief Model (HBM) were used to measure the catch-up growth status of preterm infants after discharge. Logistic regression was used to determine the risk factors for the catch-up growth of preterm infants.

RESULTS

The results showed that of 309 preterm infants, only 14 (4.5%) were underweight, and 52 (17.4%) did not meet the criteria for catch-up growth at 12 months of actual age. The logistic regression analysis showed that gestational age, regular health care, caregivers' educational background, mothers' daily contact with the baby, monthly average family income, the addition of a breast milk supplement, and daily milk volume were risk factors that affected the catch-up growth of preterm infants after discharge.

CONCLUSIONS

The rate of catch-up growth of preterm infants is still not high. We should pay much more attention to preterm infants of small gestational age and guide their child care on a regular basis to detect and correct risk factors in a timely fashion, especially those involving lower daily milk volume, lower degree of culture and family economic difficulties. Second, we suggest that the government publish relevant policy that appropriately increases the length of maternity leave for preterm mothers. Future studies should have larger sample sizes and explore other important factors influencing the catch-up growth of preterm infants.

Early nutrition and signs of metabolic syndrome at 6 y of age in children born very preterm

Background

In term-born infants, the risk of developing metabolic syndrome (MetS) has been shown to be associated with formula feeding and early rapid growth. Breastfeeding, however, seems to be associated with a lower risk of MetS among term-born infants.

Objective

The possible association between type of early nutrition, early growth, and possible influence on different metabolic outcomes at 6 y of age was investigated in very-preterm-born children.

Design

This study is a 6-y follow-up of 281 very-preterm-born infants with a gestational age of ≤32 wk. Infants breastfed at discharge from the hospital were randomly assigned to receive unfortified or fortified mother's milk, whereas those who were not breastfed received a preterm formula. The intervention lasted until 4 mo of corrected age. At 6 y of age, height, weight, and body mass index were measured and a dual-energy X-ray absorptiometry scan and blood sampling were performed.

Results

In total, 239 children participated in the follow-up. No differences were found between the 2 breastfed groups. Formula-fed children were more often predisposed to obesity and from families with a lower social status than were children who were breastfed only. Early rapid growth (crossing of weight percentiles with >1 SD in either direction) was seen in 53% of the children from 34 wk of postmenstrual age and until 2 mo of corrected age and was significantly correlated with several metabolic outcomes at 6 y of age.

Conclusions

Children fed a preterm formula postdischarge more often showed early rapid growth than did breastfed children, and early rapid growth was correlated with early signs of MetS at 6 y of age. However, all of the values were within normal ranges. This trial was registered at as NCT02078687.

Cost analysis of neonatal tele-homecare for preterm infants compared to hospital-based care

Introduction

Neonatal homecare (NH) can be used to provide parents the opportunity of bringing cardiopulmonary-stable preterm infants home for tube feeding and the establishment of breastfeeding supported by neonatal nurses visiting the home. However, home visits can be challenging for hospitals covering large regions, and, therefore, regular neonatal hospital care has remained the first choice in Denmark. As an alternative to home visits, telehealth may be used to deliver NH. Thus, neonatal tele-homecare (NTH) was developed. Positive infant outcomes and the optimization of family-centred care have been described, but the costs of telehealth in the context of NH remain unknown. This study aims to assess the costs of NTH compared to regular neonatal hospital care, from the health service perspective.

Methods

The cost analysis was based on an observational study of NTH in Denmark (run from November 2015 to December 2016) and followed the Consolidated Health Economic Evaluation Reporting Standards. The intervention group were the families of preterm infants receiving NTH ( n = 96). The control group comprised a historic cohort of families with preterm infants, receiving standard care in the neonatal intensive care unit (NICU) ( n = 278). NTH infants and the historical group were categorized according to gestational age at birth at/under and over 32 weeks. The outcomes were NTH resource utilization, in-NICU hospital bed days, re-admissions and total costs on average per infant. The time horizon was from birth to discharge.

Results

The costs of NTH resource utilization were, on average, €695 per infant, and the total costs per infant, on average, were €12,200 and €4200 for infants at/under and over 32 weeks, respectively. The corresponding costs of the control group were €14,300 and €4400. The difference in total costs showed statistical significance for the group of infants under 32 weeks ( p < 0.001).

Discussion

The cost analysis showed that NTH was less costly compared to regular hospital care, especially for infants born with gestational age at/under 32 weeks. NTH is an appropriate model of care for preterm infants and their families, is clinically effective and less expensive than similar services delivered in the hospital.

Fortification of Human Milk for Preterm Infants: Update and Recommendations of the European Milk Bank Association (EMBA) Working Group on Human Milk Fortification

Evidence indicates that human milk (HM) is the best form of nutrition uniquely suited not only to term but also to preterm infants conferring health benefits in both the short and long-term. However, HM does not provide sufficient nutrition for the very low birth weight (VLBW) infant when fed at the usual feeding volumes leading to slow growth with the risk of neurocognitive impairment and other poor health outcomes such as retinopathy and bronchopulmonary dysplasia. HM should be supplemented (fortified) with the nutrients in short supply, particularly with protein, calcium, and phosphate to meet the high requirements of this group of babies. In this paper the European Milk Bank Association (EMBA) Working Group on HM Fortification discusses the existing evidence in this field, gives an overview of different fortification approaches and definitions, outlines the gaps in knowledge and gives recommendations for practice and suggestions for future research. EMBA recognizes that "Standard Fortification," which is currently the most utilized regimen in neonatal intensive care units, still falls short in supplying sufficient protein for some VLBW infants. EMBA encourages the use of "Individualized Fortification" to optimize nutrient intake. "Adjustable Fortification" and "Targeted Fortification" are 2 methods of individualized fortification. The quality and source of human milk fortifiers constitute another important topic. There is work looking at human milk derived fortifiers, but it is still too early to draw precise conclusions about their use. The pros and cons are discussed in this Commentary in addition to the evidence around use of fortifiers post discharge.

Improved lung function at age 6 in children born very preterm and fed extra protein post-discharge

BACKGROUND

In very preterm-born children, alveolar maturation is challenged and lung function is often compromised during childhood. So far, very few studies have focused on type of early nutrition and lung function in children born preterm.

METHODS

This study is a 6 years follow-up of 281 very preterm-born infants (VPI) with a gestational age (GA) <32 + 0 weeks. Infants breastfed at discharge from hospital were randomized to unfortified (UHM) or fortified (FHM) mother's (human) milk, whereas those not breastfed received a preterm formula (PF). The intervention lasted until 4 months corrected age. At 6 years of age fractional exhaled nitric oxide (FeNO), airway resistance and occlusion measurements with reversibility were performed. Data on predisposition to asthma and allergy as well as possible allergic symptoms of the child were obtained with questionnaires.

RESULTS

Outcome data was fully or partially available on 160 (66.9%) of 239 children. This included 49 (30.6%) children fed UHM, 58 (36.3%) fed FHM and 53 (33.1%) fed PF. Successful FeNO measurements were obtained in 119 (74.4%) children and airway resistance measurements in 160. FeNO results were not significantly different between feeding groups. Children fed a protein-enriched diet (FMH/PF) had the lowest, for example, best, airway resistance; FHM-fed had lower values than UHM-fed (P = 0.042) before, and PF-fed had significantly lower values than UHM-fed after beta-2-agonist inhalation (P = 0.050). The tendency of lower airway resistance when protein enriched were the same in gender-specific analyses. In SGA children, the same tendency was found between PF- and UHM-fed (P = 0.007 before and P = 0.046 after beta-2-agonist inhalation). All values were within reference limits.

CONCLUSIONS

Lung function in very preterm-born children may improve when fed a protein-enriched nutrition post-discharge.

Growth and breastfeeding of preterm infants receiving neonatal tele-homecare compared to hospital-based care

OBJECTIVE

Neonatal tele-homecare implies that parents of clinically stable preterm infants can manage tube feeding and establishment of oral feeding in the home. Support is provided from the neonatal intensive care unit (NICU) through a telehealth service. The aim of this study was to compare growth and breastfeeding rates amongst infants being managed in the NICU (conventional care) and by neonatal tele-homecare.

METHODS

A total of 96 preterm infants with tube feeding requirements participated in the observational study of neonatal tele-homecare. Retrospective data in 278 preterm infants receiving standard care in the same neonatal intensive care unit prior to implementation of neonatal tele-homecare were used for comparison. Rates of breastfeeding and growth were monitored during neonatal tele-homecare. Infant weights were converted to standard deviation weight-for-age z-scores based on a reference.

RESULTS

There was no significant difference in rates of exclusive breastfeeding between the neonatal tele-homecare infants and the controls. Among the very preterm singleton infants more neonatal tele-homecare infants were exclusively breastfed at discharge compared to the controls (p = 0.04). There was no significant difference in median weight for age z-scores at discharge.

CONCLUSION

This study demonstrates that neonatal tele-homecare may be an appropriate model of care for the management of preterm infants outside of the hospital environment; with the added benefit of higher rates of breastfeeding at time of discharge for very preterm infants.

Infant Feeding Practices and Weight Gain in Toddlers Born Very Preterm: A Pilot Study

PURPOSE

Long-term consequences of prematurity are a public health concern. A pattern of slow initial weight gain followed by a period of rapid weight gain has been associated with poor cardiometabolic health outcomes. The purpose of this study was to examine the relationships between infant feeding practices and weight gain in a sample of 18-to-24-month olds corrected age born very preterm.

DESIGN AND METHODS

A cross-sectional design was used to examine the relationships between infant feeding practices and weight gain. Estimates of effect sizes and model fit estimates were the primary parameters of interest.

RESULTS

Most of the participants received human milk after birth, but most had transitioned to formula before three months. Slightly less than half received complementary foods prior to four months corrected age. Gains in weight and head circumference were rapid after discharge from the neonatal intensive care unit, while gains in length lagged behind. Infant feeding practices did not have a clinically meaningful effect on weight gain.

CONCLUSIONS

While the initiation of human milk feedings was encouraging, the duration fell short of recommendations. Practices such as the early introduction of complementary feedings and the addition of rice cereal to the bottle are troubling. Additionally, the rapid increase in weight gain may have a negative impact on future cardiometabolic health.

PRACTICE IMPLICATIONS

Clinical recommendations include ensuring support for the use of human milk before and after hospital discharge, close monitoring of physical growth, and ensuring adherence to the guidelines for the introduction of complementary foods.

ABM Clinical Protocol #12: Transitioning the Breastfeeding Preterm Infant from the Neonatal Intensive Care Unit to Home, Revised 2018

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols, free from commercial interest or influence, for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

[Follow-up protocol for newborns of birthweight less than 1500 g or less than 32 weeks gestation]

The mortality of children with a birthweight of less than 1500g or with a gestational age of less than 32 weeks (<1500<32) has decreased significantly in the last 20 years or so. Given the higher risk of disability in these children, follow-up after hospital discharge is considered essential. In this document, the Follow-Up Group of the Spanish Society of Neonatology, in collaboration with the Spanish Society of Paediatric Primary Care, propose a follow-up protocol specific for the<1500<32, which has as its aim to standardise the activities and evaluations according to good practice criteria.

Neurodevelopmental outcomes and nutritional strategies in very low birth weight infants

The developing brain of the very low birth weight (VLBW) infant is highly sensitive to effects of the nutritional milieu during the neonatal hospitalization and after discharge. Strategies to optimize nutritional care play an important role in reducing long-term neurodevelopmental morbidities in this population. Currently available interventions to ensure that the unique nutrient requirements of the VLBW infant are met include various dietary fortification strategies and parenteral nutrition. In this article, we review evidence regarding nutritional strategies and their beneficial effects on neurodevelopment in VLBW infants. We also highlight gaps in current knowledge and areas of current investigation that hold promise for improving nutritional care and long-term outcomes.

Breast milk supplementation and preterm infant development after hospital discharge: a randomized clinical trial

OBJECTIVES

To assess the effect of maternal breast milk supplementation on the development of exclusively breast-fed very low birth weight preterm infants at 12 months of corrected age.

METHODS

A randomized clinical trial with 53 infants followed-up after discharge from the neonatal unit until a corrected gestational age of 12 months. Newborns in the intervention group were breastfed exclusively with maternal milk and received 2g of a multinutrient supplement (Pré-Nan(®), Nestlé, Vevey, Switzerland) added to expressed breast milk twice a day until a corrected age of 4-6 months. The control group was exclusively breastfed without supplementation. After monthly follow-up, developmental assessment was performed using the Bayley III Scale.

RESULTS

There was no statistically significant difference on the Bayley III Scale between the intervention and control groups in any of the assessed domains: motor, cognitive, and communication. However, scores in the three domains were always higher in the group that received the supplement. There were a similar number of cases of developmental delay in both groups: seven (28%) in the group that received the supplement and nine (33.3%) in the group that was exclusively breastfed.

CONCLUSIONS

The results failed to show an association between post-discharge multinutrient supplementation and development in the assessed infants.

Working group reports: evaluation of the evidence to support practice guidelines for nutritional care of preterm infants-the Pre-B Project

The "Evaluation of the Evidence to Support Practice Guidelines for the Nutritional Care of Preterm Infants: The Pre-B Project" is the first phase in a process to present the current state of knowledge and to support the development of evidence-informed guidance for the nutritional care of preterm and high-risk newborn infants. The future systematic reviews that will ultimately provide the underpinning for guideline development will be conducted by the Academy of Nutrition and Dietetics' Evidence Analysis Library (EAL). To accomplish the objectives of this first phase, the Pre-B Project organizers established 4 working groups (WGs) to address the following themes: 1) nutrient specifications for preterm infants, 2) clinical and practical issues in enteral feeding of preterm infants, 3) gastrointestinal and surgical issues, and 4) current standards of infant feeding. Each WG was asked to 1) develop a series of topics relevant to their respective themes, 2) identify questions for which there is sufficient evidence to support a systematic review process conducted by the EAL, and 3) develop a research agenda to address priority gaps in our understanding of the role of nutrition in health and development of preterm/neonatal intensive care unit infants. This article is a summary of the reports from the 4 Pre-B WGs.

Nutritional support for premature infants in the neonatal intensive care unit

Nutritional support for premature infants in the neonatal intensive care unit setting is complex. Such infants have conditions unique to this period of the lifespan requiring specialized care management, both of which may impede the provision of adequate nutrition to support basal metabolic needs. Premature infants require optimum nutritional intake to support rapid growth during a time when they are not fully capable of tolerating it. This article reviews developmental anatomy, physiology, and the effect of premature delivery by systems; the challenges of providing adequate nutrition; and current evidence-based strategies to provide nutrition for premature infants during hospitalization.

Managing the Human-Milk-Fed, Preterm, VLBW Infant at NICU Discharge

Feeding prematurely born infants after their stay in the neonatal intensive care unit (NICU) remains problematic. Growth in the NICU is almost always well below the intrauterine rate, and extrauterine growth restriction is common. Breastfeeding is difficult in the NICU, and human milk alone may not always provide adequate protein or minerals for optimal growth. At the time of NICU discharge, a regimen is needed that is supportive of both ongoing lactation and optimal nutrition. However, there is no one regimen that suits all babies and families. We propose a simplified algorithm to help guide the clinical team in deciding what dietary regimen is best suited for their patients.

Accounting for multiple births in randomised trials: a systematic review

OBJECTIVES

Multiple births are an important subgroup to consider in trials aimed at reducing preterm birth or its consequences. Including multiples results in a unique mixture of independent and clustered data, which has implications for the design, analysis and reporting of the trial. We aimed to determine how multiple births were taken into account in the design and analysis of recent trials involving preterm infants, and whether key information relevant to multiple births was reported.

DESIGN

We conducted a systematic review of multicentre randomised trials involving preterm infants published between 2008 and 2013. Information relevant to multiple births was extracted.

RESULTS

Of the 56 trials included in the review, 6 (11%) excluded multiples and 24 (43%) failed to indicate whether multiples were included. Among the 26 trials that reported multiples were included, only one (4%) accounted for clustering in the sample size calculations and eight (31%) took the clustering into account in the analysis of the primary outcome. Of the 20 trials that randomised infants, 12 (60%) failed to report how infants from the same birth were randomised.

CONCLUSIONS

Information on multiple births is often poorly reported in trials involving preterm infants, and clustering due to multiple births is rarely taken into account. Since ignoring clustering could result in inappropriate recommendations for clinical practice, clustering should be taken into account in the design and analysis of future neonatal and perinatal trials including infants from a multiple birth.

Managing the Human-Milk-Fed, Preterm, VLBW Infant at NICU Discharge

Preterm, very-low-birth-weight (VLBW) infants are at high nutritional risk because of poor nutrient stores at birth, digestive and neurodevelopmental immaturity, and increased risk of medical and surgical complications. Human milk (HM) is the preferred feeding for nearly all newborns. It is easily digested, well absorbed, and decreases the risk of infection. To meet the nutritional needs of small babies, however, HM requires fortification. HM fortification is the accepted norm during neonatal intensive care unit (NICU) hospitalization. This article reviews how to manage the human-milk-fed preterm VLBW infant at NICU discharge. Recent evidence suggests that HM alone after discharge may not replenish nutrient deficits accumulated during the hospital stay or sustain growth in the immediate follow-up period. Practitioners are challenged with devising nutritionally adequate diets that are practical and sustainable while preserving the HM supply and protecting the breastfeeding experience. We will review the available science; reveal pitfalls in common practices, including “the sprinkles dilemma”; and present several options for regimens that meet nutritional goals.

Preterm dietary study: meal frequency, regurgitation and the surprisingly high use of laxatives among formula-fed infants following discharge

AIM

To describe eating habits and possible feeding intolerance among preterm infants based on type of nutrition.

METHODS

The parents of infants born below 32 weeks filled in questionnaires, before and after discharge, about type of nutrition, number of meals, regurgitation, number of stools and laxative use.

RESULTS

A total of 769 questionnaires based on 286 very preterm infants were completed, and 753 were included. At 40 weeks of corrected age, infants fed both fortified and unfortified human milk received more daily meals (mean 7.37 and 7.57) than preterm formula-fed infants (mean 6.79) (p < 0.05). Fortification of human milk did not seem to increase the incidence of regurgitation. Between 38.7 and 42.9% of the preterm infants were treated with laxatives from discharge to 6 months of corrected age. Infants fed preterm formula prior to discharge, at term, at 2 and 4 months of corrected age received laxatives more often than infants fed human milk, with odds ratios of 13.7, 137.5, 49.7 and 40.5, respectively (p ≤ 0.001).

CONCLUSION

Constipation seems to be frequent among very preterm infants. Laxative use averaged 40% across all the different feeding groups and was as high as 70-85% in formula-fed preterm infants over the course of the study.

Post-discharge nutrition of the breastfed preterm infant

Provision of mother's own milk is the optimal way to nourish infants, including the preterm infant. The importance of mother's own milk during initial hospitalization to improve feeding tolerance, reduce serious infection and necrotizing enterocolitis is well appreciated. As a result, there has been a culture shift in neonatology such that breastfeeding is now encouraged and the majority of mothers of preterm infants attempt to express breastmilk. While more can be done during the hospital stay, nutrient intakes and growth are monitored and lactation support is provided. After hospital discharge, however, nutrient intakes and growth are frequently not monitored in a coordinated fashion and lactation support is often inaccessible. Few data are available to guide the clinician on the best approach to supporting the breastfed infant after discharge and expert guidance is frequently non-existent. This review provides evidence for a 'proactive' rather than a 'reactive' approach to supporting the breastfed preterm infant after discharge in terms of breastfeeding promotion, resolving acquired nutrient deficits, normalizing feeding and promoting optimal growth.

Nutritional recommendations for the late-preterm infant and the preterm infant after hospital discharge

Early nutritional support of preterm infants is critical to life-long health and well being. Numerous studies have demonstrated that preterm infants are at increased risk of mortality and morbidity, including disturbances in brain development. To date, much attention has focused on enhancing the nutritional support of very low and extremely low birth weight infants to improve survival and quality of life. In most countries, preterm infants are sent home before their expected date of term birth for economic or other reasons. It is debatable whether these newborns require special nutritional regimens or discharge formulas. Furthermore, guidelines that specify how to feed very preterm infants after hospital discharge are scarce and conflicting. On the other hand, the late-preterm infant presents a challenge to health care providers immediately after birth when decisions must be made about how and where to care for these newborns. Considering these infants as well babies may place them at a disadvantage. Late-preterm infants have unique and often-unrecognized medical vulnerabilities and nutritional needs that predispose them to greater rates of morbidity and hospital readmissions. Poor or inadequate feeding during hospitalization may be one of the main reasons why late-preterm infants have difficulty gaining weight right after birth. Providing optimal nutritional support to late premature infants may improve survival and quality of life as it does for very preterm infants. In this work, we present a review of the literature and provide separate recommendations for the care and feeding of late-preterm infants and very preterm infants after discharge. We identify gaps in current knowledge as well as priorities for future research.

Multinutrient fortification of human breast milk for preterm infants following hospital discharge

BACKGROUND

Preterm infants are usually growth restricted at hospital discharge. Feeding preterm infants after hospital discharge with multinutrient fortified breast milk rather than unfortified breast milk may facilitate more rapid catch-up growth and improve neurodevelopmental outcomes.

OBJECTIVES

To determine the effect of feeding preterm infants following hospital discharge with multinutrient fortified human breast milk versus unfortified breast milk on growth and development.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group. This included electronic searches of the Cochrane Central Register of Controlled Trials Register (CENTRAL, The Cochrane Library, 2012, Issue 3), MEDLINE, EMBASE and CINAHL (until August 2012), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that compared feeding preterm infants following hospital discharge with multinutrient fortified breast milk compared with unfortified human breast milk.

DATA COLLECTION AND ANALYSIS

We extracted data using the standard methods of the Cochrane Neonatal Review Group with separate evaluation of trial quality and data extraction by two review authors and synthesis of data using risk ratio, risk difference and mean difference.

MAIN RESULTS

We identified two small trials involving a total of 246 infants. These did not provide evidence that multinutrient fortification of breast milk for three to four months after hospital discharge affected rates of growth during infancy. One trial assessed infants at 18 months corrected age and did not find any statistically significant effects on neurodevelopmental outcomes.

AUTHORS' CONCLUSIONS

The limited available data do not provide convincing evidence that feeding preterm infants with multinutrient fortified breast milk compared with unfortified breast milk following hospital discharge affects important outcomes including growth rates during infancy. There are no data on long-term growth. Since fortifying breast milk for infants fed directly from the breast is logistically difficult and has the potential to interfere with breast feeding, it is important to determine if mothers would support further trials of this intervention.

Designer foods and their benefits: A review

Designer foods are normal foods fortified with health promoting ingredients. These foods are similar in appearance to normal foods and are consumed regularly as a part of diet. In this article we have reviewed the global regulatory status and benefits of available designer foods such as designer egg, designer milk, designer grains, probiotics, designer foods enriched with micro and macronutrients and designer proteins. Designer foods are produced by the process of fortification or nutrification. With the advances in the biotechnology, biofortification of foods using technologies such as recombinant DNA technology and fermentation procedures are gaining advantage in the industry. The ultimate acceptability and extensive use of designer foods depend on proper regulation in the market by the regulatory authorities of the country and by creating consumer awareness about their health benefits through various nationwide programs.

Neonatal management and safe discharge of late and moderate preterm infants

Late and moderate preterm infants form the majority of admissions for prematurity to special care neonatal nurseries. Although at risk for acute disorders of prematurity, they do not suffer the serious long term risks and chronic illnesses of the extremely premature. The special challenges addressed here are of transition and of thermal adaptation, nutritional compensation for postnatal growth restriction, the establishment of early feeding, and the avoidance of post-discharge jaundice or apnea. These 'healthy' premature infants provide challenges for discharge planning, in that opportunities may be available for discharge well before the expected date of delivery, which should be pursued. Barriers to early discharge are rigid conservative protocols and unwarranted investigations; facilitators of discharge are individualized care by nurses expert in cue-based feeding, early management of the thermal environment, support of family preferences and encouragement of mother-baby interactions. Safe discharge depends on recognizing these opportunities and applying strategies to address them.

Empirical evaluation of age groups and age-subgroup analyses in pediatric randomized trials and pediatric meta-analyses

BACKGROUND

An important step toward improvement of the conduct of pediatric clinical research is the standardization of the ages of children to be included in pediatric trials and the optimal age-subgroups to be analyzed.

METHODS

We set out to evaluate empirically the age ranges of children, and age-subgroup analyses thereof, reported in recent pediatric randomized clinical trials (RCTs) and meta-analyses. First, we screened 24 RCTs published in Pediatrics during the first 6 months of 2011; second, we screened 188 pediatric RCTs published in 2007 in the Cochrane Central Register of Controlled Trials; third, we screened 48 pediatric meta-analyses published in the Cochrane Database of Systematic Reviews in 2011. We extracted information on age ranges and age-subgroups considered and age-subgroup differences reported.

RESULTS

The age range of children in RCTs published in Pediatrics varied from 0.1 to 17.5 years (median age: 5; interquartile range: 1.8-10.2) and only 25% of those presented age-subgroup analyses. Large variability was also detected for age ranges in 188 RCTs from the Cochrane Central Register of Controlled Trials, and only 28 of those analyzed age-subgroups. Moreover, only 11 of 48 meta-analyses had age-subgroup analyses, and in 6 of those, only different studies were included. Furthermore, most of these observed differences were not beyond chance.

CONCLUSIONS

We observed large variability in the age ranges and age-subgroups of children included in recent pediatric trials and meta-analyses. Despite the limited available data, some age-subgroup differences were noted. The rationale for the selection of particular age-subgroups deserves further study.

Definition and outpatient management of the very low-birth-weight infant with bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD), also known as chronic lung disease of prematurity, is the major cause of pulmonary disease in infants. The pathophysiology and management of BPD have evolved over the past four decades as improved neonatal intensive care unit (NICU) modalities have increased survival rates. The likelihood for developing BPD increases with the degree of prematurity and reaches 25-35% in very low-birth-weight and extremely low-birth-weight infants. BPD affects many organ systems, and infants with BPD are at increased risk for rehospitalization and numerous complications following NICU discharge. The management of BPD and medically related problems, particularly during the first 2 years of life, remains a continuing challenge for parents and healthcare providers. It is important that a multidisciplinary team consisting of the neonatologist/attending physician, primary care physician, and other specialized support staff work in concert and meet regularly to provide continuity of care and accurate patient assessments.