New Insights in Preterm Nutrition

Predictors of time to full enteral feeding in low birth weight neonates admitted to neonatal intensive care unit: a prospective follow up study

BACKGROUND

Survival of LBW infants has increased in recent years because of novel perinatal interventions, but the introduction and advancement of enteral feeds for low birth weight infants is challenging. In Ethiopia the proportion of low birth weight infants is thought to be 17.3%. The purpose of this study was to determine the time to full enteral feeding (FEF) and its predictors in LBW neonates admitted to neonatal intensive care unit in selected hospitals of Addis Ababa, Ethiopia.

METHOD

An institutional based prospective follow up study was conducted from March 15 to June 15, 2022 among 282 LBW neonates admitted to six randomly selected hospitals. Both primary and secondary data was used by interviewing mothers and prospective medical chart review of neonates. The Cox regression model was used and variables having a p-value less than 0.05 with 95% CIs in a multivariable analysis were declared as statistically significant association with time to full enteral feeding.

RESULT

Out of 282 neonates involved in this study, 211 (74.8%) of them reached at FEF. The overall median time to full enteral feeding was 5 days. Predictors significantly associated with time to full enteral feeding were educational level, birth weight, cesarean delivery, hospital acquired infection, being on antibiotics, age at initiation of trophic feeding, routine gastric residual evaluation and NICU location (hospital).

CONCLUSIONS

This study demonstrated the difficulty of understanding which low birth weight neonate will attain FEF in a timely manner and factors that affect time to FEF. There is a delay in full enteral feeding achievement among low birth weight neonates and there is a great deal of heterogeneity of practice among health care providers regarding feeding of infants as it was evidenced by a variation in feeding practice among hospitals. Nutrition should be considered as part of the management in neonatal intensive care units since low birth weight neonates are developing edematous malnutrition while they are in the NICU. There should be standard feeding protocol to avoid heterogeneity of practice and additional study should be conducted for each categories of GA and BW with long follow up time.

Combined Nutrition in Very-Low-Birth-Weight Preterm Infants in the Neonatal Intensive Care Unit

Background Adequate nutritional support is crucial for achieving optimal growth and development in very-low-birth-weight (VLBW) preterm infants. This study evaluated the efficacy of combined nutrition (CN) (parenteral plus enteral nutrition (EN)) as an alternative nutrition protocol for VLBW infants in the neonatal intensive care unit (NICU). Methods This retrospective cohort study collected clinical and growth data from the medical records of VLBW infants weighing between 1,000 and 1,500 grams in the NICU of the Hospital of Obstetrics and Gynecology "Dr. Víctor Manuel Espinosa de los Reyes Sánchez" of the Centro Médico Nacional "La Raza" Instituto Mexicano del Seguro Social, Mexico. Parenteral nutrition (PN) alone or CN (PN plus EN) was used for nutritional management. Statistical tests, such as Student's t-test, Mann-Whitney U test, and chi-square test as appropriate, were used to compare the clinical characteristics and growth data of the two groups, and relative risk was calculated to determine the probability of comorbidities according to feeding type. Statistical significance was set at p<0.05. Results The study included 90 VLBW infants, with 27 receiving PN alone and 63 receiving CN. No statistically significant differences were found concerning sex, age, or Apgar score. The CN group showed better weight gain with statistically significant differences at 28 days (p=0.002), with no increase in the relative risk of necrotizing enterocolitis (NEC) or other complications. Conclusions The CN protocol met the caloric and nutritional needs, without increasing morbidity and mortality. The protocol had a positive impact on weight gain and a shorter NICU stay and should be considered as a nutritional alternative for VLBW infants.

Nutritional Supplements to Improve Outcomes in Preterm Neonates

Preterm infants are at higher risk of mortality and morbidity compared with those born at term. Nutrition-related morbidities include poor growth, immune deficiency, nutritional deficiencies, and adverse long-term neurodevelopment. In addition to macronutrients, many nutritional supplements have been used to enhance growth and development, and decrease infections. Nutrients can enhance preterm infants' immune status, optimize the microbiome, improve growth and development, and influence the risk of necrotizing enterocolitis, sepsis, and other outcomes.

Longitudinal Serum Metabolomics in Extremely Premature Infants: Relationships With Gestational Age, Nutrition, and Morbidities

An increasing number of extremely premature infants survive the neonatal period and beyond. Little is known about the maturation of the preterm infant’s metabolome and its relation to the development of morbidities. Using 1H-NMR, we investigated the serum metabolic profile of 87 infants born at a gestational age (GA) <28 weeks [mean GA (SD) 25.4 (1.4) weeks] in samples longitudinally collected from birth to term equivalent age. The infant metabolome was analyzed in relation to GA, postnatal age, nutrition, and preterm morbidities. At postnatal day 1, low GA correlated with high levels of 3-hydroxyisobutyrate, acetate, acetoacetate, acetone, formate, glucose, and valine. Nearly all quantified metabolites displayed postnatal concentration changes. For example, the two phospholipid-related metabolites myo-inositol and ethanolamine displayed a similar decline from birth over the first weeks of life, irrespectively of GA. The proportion of enteral/parenteral energy intake in the first 28 days significantly correlated with mean levels of 52% of the analyzed metabolites. Low enteral energy intake was associated with high serum levels of 3-hydroxyisobutyrate, creatinine, glucose, glycerol, histidine, lactate, leucine, lysine, methionine, ornithine, phenylalanine, proline, threonine, and uridine. There were also significant correlations between high enteral intake and high serum levels of isoleucine and tyrosine. Retinopathy of prematurity (ROP) and bronchopulmonary dysplasia (BPD) outcomes were not significantly associated with metabolite levels in the neonatal period after correcting for multiple testing. In conclusion, the serum metabolome of extremely premature infants changes substantially in the neonatal period, largely driven by the gradual transfer from total parenteral nutrition to full enteral feeding. Further studies are needed to disentangle the intricate relationships between the metabolome, nutritional management, GA, and the development of preterm morbidities.

The Effect of High Glucose Intake on Weight Gain in Very Low Birth Weight Neonates: A Randomized Controlled Trial

This study aims at evaluating the effect of high glucose intake as a component of total parenteral nutrition on birth weight (BW) regain in very low birth weight neonates. Ninety newborns with BW <1500 g were randomized to control or experimental groups. Both groups received the same total parenteral nutrition regimens except glucose intake provided by dextrose water (DW) serum: 7 to 15 g/kg/d (10% DW) in the former versus 8.75 to 18.75 g/kg/d (12.5% DW) in the latter. Body weight as the primary outcome was monitored until the BW was regained. Results revealed that neonates who received 12.5% DW regained BW significantly faster (10.98 ± 2.46 vs 13.24 ± 4.03 days, P = .024) and needed lesser duration of respiratory support (5.34 ± 2.11 vs 7.17 ± 3.19 days, P = .003). As the proposed intervention can reduce neonatal intensive care unit admission duration, it mitigates risks of health care-associated infections, while favorably affecting the health economy.

Evidence summary of human milk fortifier in preterm infants

BACKGROUND

To search for and collect evidence on human milk fortifier in preterm infants, and to summarize the latest and best evidence, so as to provide reference for clinical work.

METHODS

We searched the databases of UpToDate, American Guide Network, Cochrane Library, Joanna Briggs Institute (JBI), PubMed, ResearchGate, China National Knowledge Infrastructure (CNKI), Wan Fang, Chinese Biology Medicine disc (CBM), and Yi Maitong, and collected relevant guidelines, systematic reviews, evidence summaries, expert consensuses, and randomized controlled trials (RCTs). The retrieval time limit was from the database establishment to July 2021. The quality of the literature was independently evaluated by 2 researchers, who then extracted and summarized the evidence from qualifying articles.

RESULTS

A total of 16 articles were selected, including 3 guidelines, 3 systematic reviews, 5 expert consensuses, 3 RCTs, and 1 best practice guideline, including indications, time for usage, methods, monitoring and management, time of cessation, health education, and post-discharge feeding.

CONCLUSIONS

This study summarized the best evidence for human milk fortifier in preterm infants. Medical staff should assess the specific clinical conditions and parental wishes when applying the best evidence to ensure the effectiveness and safety of human milk fortifier, thus improving the quality of clinical nursing.

Optimizing parenteral nutrition to achieve an adequate weight gain according to the current guidelines in preterm infants with birth weight less than 1500 g: a prospective observational study

Aim

European Society for Clinical Nutrition and Metabolism released the guidelines on pediatric parenteral nutrition in 2018. We aimed to compare the parenteral nutrition (PN) regimen with the current guidelines, evaluate weight gain and explore the correlation of parenteral macronutrient and energy intakes with weight gain outcome in preterm infants with birth weight less than 1500 g.

Methods

A prospective observational study was conducted. Parenteral macronutrients and energy intakes were described. Weight gain during PN was assessed. Nutritional factors associated with weight gain outcome after PN were identified using a cox proportional hazards model.

Results

A total of 163 infants were included in this study, in which 41 were extremely low birth weight (ELBW) infants and 122 were very low birth weight (VLBW) infants. Average glucose, amino acid, lipid, and energy during the first postnatal week were 7.5 g/kg/d, 2.4 g/kg/d, 0.8 g/kg/d, 48 kcal/kg/d. Median maximum glucose, amino acid, lipid, and energy were 11.1 g/kg/d, 3.5 g/kg/d, 3 g/kg/d, 78 kcal/kg/d. Median days to maximum glucose, amino acid, lipid, and energy were 10, 9, 12, 11 days. The proportion of appropriate for gestational age (AGA) infants was 76.9%. The ratio of infants without poor weight gain outcome after PN was 38%. With every 0.1 g/kg/d decrease of maximum amino acid and average lipid during the first postnatal week, the probability of appropriate weight gain outcome decreased by 77.6 and 74.4% respectively. With each additional day to maximum glucose and energy, the probability of appropriate weight gain outcome decreased by 5.6 and 6.1% respectively.

Conclusions

Most preterm infants with birth weight less than 1500 g remain below the latest recommended nutrition goals. The poor weight gain outcome of these infants after PN is related to insufficient parenteral macronutrient and energy intakes. PN strategies should be improved according to the latest evidence-based recommendations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-02782-1.

Maturation of the preterm gastrointestinal tract can be defined by host and microbial markers for digestion and barrier defense

Functionality of the gastrointestinal tract is essential for growth and development of newborns. Preterm infants have an immature gastrointestinal tract, which is a major challenge in neonatal care. This study aims to improve the understanding of gastrointestinal functionality and maturation during the early life of preterm infants by means of gastrointestinal enzyme activity assays and metaproteomics. In this single-center, observational study, preterm infants born between 24 and 33 weeks (n = 40) and term infants born between 37 and 42 weeks (n = 3), who were admitted to Isala (Zwolle, the Netherlands), were studied. Enzyme activity analyses identified active proteases in gastric aspirates of preterm infants. Metaproteomics revealed human milk, digestive and immunological proteins in gastric aspirates of preterm infants and feces of preterm and term infants. The fecal proteome of preterm infants was deprived of gastrointestinal barrier-related proteins during the first six postnatal weeks compared to term infants. In preterm infants, bacterial oxidative stress proteins were increased compared to term infants and higher birth weight correlated to higher relative abundance of bifidobacterial proteins in postnatal week 3 to 6. Our findings indicate that gastrointestinal and beneficial microbial proteins involved in gastrointestinal maturity are associated with gestational and postnatal age.

Introduction and feeding practices of solid food in preterm infants born in Salzburg!

Background

It is shown that meeting the increased nutritional demand of preterm infants from birth is not only important for survival but essentially contributes to the infants` overall development and long-term health.

While there are established guidelines for weaning term infants, evidence regarding preterm infants is scarce and less precise.

The aim of this study was to identify the current practices on introducing solids to preterm infants amongst caregivers in Salzburg and determine potential reasons for early weaning.

Methods

Altogether 68 infants born between 24 0/7 and 36 6/7 weeks were recruited and detailed structured interviews with the caregivers were conducted at 17 weeks corrected age. Weight, height and head circumference were collected.

Results

52% of the study group received solids before the recommended 17 weeks corrected age. For this group the mean age being 13.77 ± 1.11 weeks corrected age. Premature introduction of solids significantly correlates with exclusively and early formula-feeding. 34% were weaned due to recommendation by their paediatrician. 23% of the preterm infants even received solids before 12 weeks corrected age, putting them at risks for developing obesity, celiac disease and diabetes.

Conclusions

This study shows the necessity for clear guidelines regarding the introduction of complementary feeding in preterm infants as well as the importance of their implementation. Caregivers should receive information on this topic early enough and they should fully understand the difference between chronological and corrected age.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-02505-6.