Strategies of Increased Protein Intake in ELBW Infants Fed by Human Milk Lead to Long Term Benefits

Testing the reported long-term advantages of protein-fortified human milk in very low birth weight neonates

Preterm infants are at-risk for extrauterine growth restriction and downward percentile-crossing between birth and discharge. Increased energy and protein intake through fortification of human milk during the first weeks of life has been associated with improved short-term growth and better developmental outcomes. The aim of this study was to evaluate whether these benefits persist up to children school age. The study was designed as an observational study. During hospitalization, 22 very low birth weight preterm infants were fed with increasing protein fortification of human milk (protein supplemented group, PSG). As a control group (CG), 11 preterm infants were fed with standard nutrition regimen. At children school age (9-11 years), we assessed anthropometric data (weight, height, BMI), global health (renal function), and specific psychological outcomes (Child Behavior Checklist 6-18). A global homogeneity between CG and PSG groups emerged: we found no significant differences in weight, height, and BMI, nor in internalizing symptom outcomes (all ps > 0.05). However, mothers reported significantly higher externalizing symptoms for the PSG infants compared to CG infants. Therefore, neonatal enteral protein supplementation in very low birth weight preterm infants leads to no positive nor adverse consequences in long-term assessment, suggesting that benefits are restricted to the neonatal term and first years of age.

Infant-Directed Speech to 3-Month-Old Severe Preterm Infants: The Influence of Birth Weight and Maternal Depressive Symptoms

Severe premature birth (<32 weeks) is a risk factor for the development of maternal perinatal depression, while also affecting dyadic interactions and child outcomes. Although several studies have examined the impacts of prematurity and depression on early interactions, only a few studies have investigated the features of maternal verbal input. Furthermore, no study has investigated the relationship between the effect of severity of prematurity according to birth weight and maternal input. This study aimed to explore the effects of the severity of preterm birth and postnatal depression on maternal input during early interactions. The study included 64 mother-infant dyads, classified into three groups: 17 extremely low birth weight (ELBW) preterm infants, 17 very low birth weight (VLBW) preterm infants, and 30 full-term (FT) infants. At 3 months postpartum (corrected age for preterm infants), the dyads participated in a 5-min free interaction session. Maternal input was analyzed using the CHILDES system in terms of lexical and syntactic complexity (i.e., word types, word tokens, mean length of the utterance) and functional features. Maternal postnatal depression (MPD) was assessed using the Edinburgh Postnatal Depression Scale. The results showed that in high-risk conditions (i.e., ELBW preterm birth and maternal postnatal depression), maternal input was characterized by a lower frequency of affect-salient speech and a higher proportion of information-salient speech, specifically as directives and questions, suggesting that mothers in these conditions may experience more difficulty in conveying affective content to their infants. Moreover, the more frequent use of questions may reflect an interactive style characterized by a higher level of intrusiveness. These findings provide preliminary evidence of the impacts of prematurity severity and maternal depression on maternal verbal input, highlighting the importance of assessing both factors in clinical practice. Understanding the mechanisms underlying the impacts of prematurity and depression on early interactions may inform the development of tailored interventions aimed at promoting positive parent-infant interactions and child development.

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.

Parental Book-Reading to Preterm Born Infants in NICU: The Effects on Language Development in the First Two Years

Background: After preterm birth, infants are at high risk for delays in language development. A promising intervention to reduce this risk is represented by the exposure to parental voices through book-reading in Neonatal Intensive Care Units (NICU). This study investigated the possible advantages of book-reading to preterm neonates during their NICU stay on their subsequent language development. Methods: 100 families of preterm infants were recruited. The parents of 55 preterm infants (Reading Group) received a colored picture-book on NICU admission and were supported to read to their neonate as often as possible and to continue after hospital discharge. Forty-five infants (Control Group) were recruited before the beginning of the intervention. Infant language development was assessed with the Hearing and Language quotients of the Griffith Mental Development Scale at the corrected ages of 3, 6, 9, 12, 18 and 24 months. Results: Regardless of group membership, Hearing and Language mean quotients decreased between 9 and 18 months; nevertheless, this decrease was considerably reduced in the Reading group, compared to the Control Group. Conclusions: Reading in NICUs represents a suitable intervention that could positively influence language development and parent-infant relationships in preterm children. The study findings support its implementation as a preventive measure.

A systematic review of the definitions and prevalence of feeding intolerance in preterm infants

BACKGROUND & AIMS

Feeding intolerance (FI) is a common phenomenon experienced in preterm infants in neonatal intensive care units, as well as being a focus of many research studies into feeding methods, particularly in relation to comorbidities. There is no widely accepted definition of FI. This systematic review aimed to explore the range of definitions used for FI and provide an estimate of the prevalence amongst preterm infants.

METHODS

Searches were completed on MEDLINE (includes the Cochrane library), Embase, PsycInfo, CINAHL, NHS Evidence and Web of Science. Inclusion criteria; preterm infants in neonatal units, a clear definition of FI, >10 patients and be available in English language. Case reports were excluded.

RESULTS

One hundred studies were included. Definitions of FI were inconsistent. Studies were grouped according to definition used into: Group A - measuring gastric residual volume (GRV) only; group B - GRV and abdominal distension (AD); group C - GRV, AD and gastrointestinal symptoms (GI) which included any of vomiting, bilious vomiting and blood in stool; group D- GRV and GI; group E - AD and GI; group F - GI only and group G - any other elements used. Meta-analysis demonstrated that prevalence of FI between groups varied from 15 to 30% with an overall prevalence of 27% (95% confidence interval 23-31%). Group A had the highest prevalence. Review of time to full enteral feed was performed (37 studies) which demonstrated a range of 11.3-18.3 days depending on which FI definition used.

DISCUSSION

Definitions of FI in research are inconsistent, a similar finding to that seen in studies in both paediatric and adult critical care populations. The difficulty of defining FI in the preterm population is the concern regarding necrotising enterocolitis, with some studies using an overlap in their definitions, despite differing pathophysiology and management. Due to the heterogeneity of data obtained in this review regarding definitions used, further robust research is required in order to conclude which elements which should be used to define FI in this population.

PROSPERO NUMBER

CRD42019155596. Registered November 2019.

Somatic Growth of Enteral-Only Fed Extremely Low Birth Weight Infants in a Resource-Restricted Setting

AIM

To determine the growth and prevalence of extrauterine growth restriction (EUGR) in extremely low birth weight (ELBW) infants receiving enteral-only nutrition in a resource-restricted (RR) environment.

METHODS

Information on nutritional intake, provided largely from fortified breastmilk, was collected retrospectively for 72 ELBW (<1000 g) infants admitted to Tygerberg Hospital, Cape Town, South Africa over a 1 year period. Anthropometric data for the first 49 postnatal days were compared to gender-specific INTERGROWTH-21st standards.

RESULTS

Full enteral feeds (150 ml/kg) were reached by Day 10-14 with energy >100 Kcal/kg/day from Day 10, and protein >3.5 mg/kg/day from Day 14, onwards. Growth velocity remained below 15 g/kg/day at Day 49. INTERGROWTH-21st Z-scores decreased from -0.8 ± 1.1 at birth to -2.4 ± 1.5 at Day 49. Adequate weight growth velocity (≥15 g/kg/day) was associated with maternal hypertension, completed antenatal steroids, caesarean section delivery and small for gestational age status.

CONCLUSION

This is the first study to evaluate growth of ELBW infants in a RR setting where enteral-only nutrition, principally from fortified breastmilk, was the primary feeding option. The incidence of EUGR, although high, was similar to the incidence in well-resourced settings, where total parenteral nutrition is routinely provided. Lay summaryExtra-uterine growth restriction (EUGR) is high in extremely low birth weight infants receiving enteral-only nutrition. However, EUGR rates are similar to infants receiving parenteral nutrition. Despite developmental immaturity, it is possible for these infants to achieve fetal growth rates. More aggressive feeding and fortification strategies may be necessary and will need to be balanced against the risk and fear of necrotizing enterocolitis. Enteral-only feeding regimens, especially in resource-restricted environments, should be audited regularly to ensure provision of feeds with the most optimal protein, and protein to energy ratios possible.

Bacteroidota and Lachnospiraceae integration into the gut microbiome at key time points in early life are linked to infant neurodevelopment

The early life microbiome plays critical roles in host development, shaping long-term outcomes including brain functioning. It is not known which initial infant colonizers elicit optimal neurodevelopment; thus, this study investigated the association between gut microbiome succession from the first week of life and head circumference growth (HCG), the earliest validated marker for neurodevelopment. Fecal samples were collected weekly from a preterm infant cohort during their neonatal intensive care unit stay and subjected to 16S rRNA gene sequencing for evaluating gut microbiome composition, in conjunction with clinical data and head circumference measurements. Preterm infants with suboptimal HCG trajectories had a depletion in the abundance/prevalence of Bacteroidota and Lachnospiraceae, independent of morbidity and caloric restriction. The severity of gut microbiome depletion matched the timing of significant HCG pattern separation between study groups at 30-week postmenstrual age demonstrating a potential mediating relationship resultant from clinical practices. Consideration of the clinical variables indicated that optimal infant microbiome succession is primarily driven by dispersal limitation (i.e., delivery mode) and secondarily by habitat filtering (i.e., antibiotics and enteral feeding). Bacteroidota and Lachnospiraceae are known core taxa of the adult microbiome, with roles in dietary glycan foraging, beneficial metabolite production and immunity, and our work provides evidence that their integration into the gut microbiome needs to occur early for optimal neurodevelopment.

The "Fortilat" Randomized Clinical Trial Follow-Up: Neurodevelopmental Outcome at 18 Months of Age

Adequate nutrition is fundamental to neonatal survival and short-term outcomes, but it also has long-term consequences on quality of life and neurologic development of preterm infants. Donkey milk has been suggested as a valid alternative for children allergic to cows’ milk proteins, due to its biochemical similarity to human milk; we, hence, hypothesized that donkey milk could be a suitable basis for developing an innovative human milk fortifier for feeding preterm infants. The aim of the current study was to extend the findings and to evaluate the neurodevelopmental outcomes at 18 months of corrected age of the infants enrolled in the clinical trial named “Fortilat”. Infants born ≤1500 g and <32 weeks of gestational age were randomized to receive either a combination of bovine milk-based multicomponent fortifier and protein supplement or a combination of a novel multicomponent fortifier and protein supplement derived from donkey milk. The followed fortification protocol was the same for the two groups and the two diets were designed to be isoproteic and isocaloric. All infants enrolled were included in a developmental assessment program. The neurodevelopmental assessment was performed at 18 ± 6 months of corrected age. Minor and major neurodevelopmental impairment and General Quotient (GQ) at the Griffiths-II Mental Development Scale were considered. The GQ was considered both in continuous and as two classes: lower than and higher than (or equal to) a defined cutoff (GQcl). The difference in GQ and GQcl between the two arms was estimated using Mann–Whitney–Wilcoxon test or Fischer exact test, respectively, on the assumption of casual loss at follow-up. A further analysis was performed using generalized linear models. There were 103 children (bovine milk-derived fortifier arm = 54, donkey milk-derived fortifier arm = 49) included for the neurodevelopmental follow-up. All observations were included in the interval of 18 ± 6 months of corrected age. No significant difference was observed between the two arms in the incidence of neurologic sequelae and the GQs were similar in the two arms. Our results demonstrated no difference for the donkey milk-derived fortifier compared to standard bovine-derived fortifier regarding long-term neurodevelopmental outcomes.

Developmental Dimensions in Preterm Infants During the 1st Year of Life: The Influence of Severity of Prematurity and Maternal Generalized Anxiety

BACKGROUND

The literature has recognized premature birth as a risk factor for infant development and maternal anxiety. This study investigated the impact of the severity of birth weight, as well as of maternal anxiety at 3 months of infants' corrected age, on infants' outcomes during the 1st year postpartum. Moreover, it described the longitudinal trajectories of developmental outcomes, additionally exploring the impact of anxiety.

METHODS

The study compared 147 mothers and their 147 newborns, differentiated in 25 Extremely Low Birth Weight (ELBW), 41 Very Low Birth Weight (VLBW), and 81 Full-Term (FT) infants. At 3, 9, and 12 months (corrected age in the case of preterm infants) the level of infants' development was investigated according to the 5 quotients (Locomotor, Personal and Social, Hearing and Language, Eye-hand Co-ordination and Performance) of the Griffiths Mental Development Scales (GMDS-R). During the assessment of 3 months, mothers fulfilled Penn State Worry Questionnaire (PSWQ) to evaluate the presence of generalized anxiety.

RESULTS

Among the 5 GMDS-R quotients, significant effect of severity of birth weight emerged only for Performance quotient: preterm infants (ELBW at 3 months; VLBW at 12 months) showed lower scores than FT ones. Moreover, this quotient decreased from 3 to 9 and to 12 months for VLBW and FT infants, while it was stable for ELBW ones. A significant interaction between severity of birth weight and maternal anxiety emerged for Hearing and Language and Locomotor quotients. In the first case, scores for ELBW infants, independently from maternal anxiety, decreased from 9 to 12 months. The same results emerged for VLBW infants, in the case of non-anxious mothers. Regarding Locomotor quotient, mean scores decreased from 3 to 9 and to 12 months for all groups in the case of non-anxious mothers. Conversely, when mothers were anxious, this decrease emerged only for VLBW infants. Lastly, ELBW, VLBW and FT showed difference in the growth and slope of the trajectories of different quotients.

CONCLUSION

The severity of birth weight for preterm infants, also in interaction with maternal anxiety, had significant and specific impact on different dimensions of infants' development. Clinical implications of these results underline the need for individualized interventions.

Exposure to placental insufficiency alters postnatal growth trajectory in extremely low birth weight infants

Growth in the immediate postnatal period for extremely low birth weight (ELBW, birth weight < 1000 g) infants is an important topic in neonatal medicine. The goal is to ensure adequate postnatal growth and to minimize complications resulting from suboptimal growth. Past efforts have focused on postnatal nutrition as well as on minimizing comorbidities. It has not been systematically assessed whether antenatal factors play a role in postnatal growth. In this report, we conducted a retrospective study on 91 maternal-neonatal pairs. We prospectively collected maternal and neonatal demographic data, neonatal nutrition in the first 7 days of life and after enteral nutrition is fully established, comorbidity data, as well as weight data from birth to 50 weeks corrected gestational age. We developed a linear mixed-effects model to examine the role of placental insufficiency, as defined by fetal Doppler studies, in postnatal weight z-score trajectory over time in the ELBW population. We relied on Akaike Information Criterion (AIC) and Bayesian Information Criterion (BIC) for model selection. Interestingly, the selected model included a quadratic term of time and a placental insufficiency-by-time interaction term. In a covariate analysis, AIC and BIC both favored a model that included calories intake in the first 7 days of life and the total duration of antibiotics as fixed-effects, but not their interaction terms with time. Overall, we demonstrated for the first time that placental insufficiency, an antenatal factor, is a major determinant of postnatal weight trajectory in the ELBW population. Prospective studies are warranted to confirm our findings.