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

The Effects of Early Enteral and Parental Nutrition on Retinopathy of Prematurity: A Systematic Review

The management of preterm newborns must consider the severe problem of retinopathy of prematurity (ROP). A systematic review has been conducted to effectively acknowledge how enteral and parenteral early nutrition affect the growth and progression of ROP. The study summarizes recent findings from various sources to give insight into the relationship between dietary practices and ROP risks. When untreated, retinopathy of prematurity (ROP) may cause severe vision loss or blindness in premature newborns. The latter two phases of ROP progression are the most serious. A child's early nutrition, both orally and intravenously, significantly impacts the severity and progression of ROP. This systematic review aims to examine the evidence linking early nutrition to ROP in premature infants. The study used Embase, Scopus, and PubMed to conduct our search. ROP, premature newborns, and nutrition were keywords used to find relevant papers. Nine research studies made it through the screening process and offered important information on the impact of diet on ROP. These studies support the idea that poor nutrition is a driving force behind the onset of ROP. The risk of ROP has been associated with postnatal development, hyperglycemia, polyunsaturated fatty acid levels, and the presence of breast milk. The outlook for ROP has also been discovered to be affected by the length of time the patient has received parenteral feeding. The incidence and severity of ROP may be mitigated by providing better nutrition to premature newborns. This comprehensive study concludes that early nutrition, both enteral and parenteral, substantially influences the development and progression of ROP in premature newborns. The significance of nutrition in newborn care is highlighted by the possibility that improved dietary methods might aid in preventing and treating this vision-threatening illness.

Is It Time to Revise the Current Nutrient Requirements for Infant Formulas Principally Established in 1980?

Because of the production of nutrient-deficient infant formulas (IFs), the United States Congress passed regulations on the composition and production of IF, referred to as the Infant Formula Act (IFA), in 1980, which was amended in 1986. More detailed FDA rules have been created since then, specifying the ranges or minimum intakes of nutrients and providing details for the safe production and evaluation of infant formulas. Although generally effective in ensuring safe IF, recent events have made it clear that a re-evaluation of aspects of all the nutrient composition regulations for IF is needed, including consideration of adding requirements related to bioactive nutrients not mentioned in the IFA. We propose that, as principal examples, the requirement for iron content needs to be re-evaluated and that DHA and AA should be considered for addition to the nutrient requirements after scientific review by a panel such as those established by the National Academies of Sciences, Engineering, and Medicine. Additionally, there is no specific requirement in current FDA regulations for the energy density of IF, and this should be added alongside potential revisions of the protein requirement. It would also be ideal to have specific FDA rules on nutrient intakes for premature infants as these are exempted from the specific nutrient regulations of the amended IFA.

Frequency-specific electrogastrography as a non-invasive tool to measure gastrointestinal maturity in preterm infants

Enteral feeding is challenging in preterm infants because of gastrointestinal (GI) immaturity. Electrogastrography (EGG) is a non-invasive technology that measures gastric myoelectrical activity and can be utilized to measure changes that occur with maturation at different gestational ages (GA). Three gastric rhythms (GR) exist between 0.5-9 cycles per minute (cpm), namely, bradygastria (0.5 ≤ GR < 2 cpm), normogastria (2 ≤ GR < 4 cpm), and tachygastria (4 ≤ GR < 9 cpm). We aimed to characterize EGG-derived parameters for different GA by quantifying (1) power spectral density (PSD) and its spectral means at three GR bands (i.e., mPSD_GR) and (2) the percent (%) time spent in each band. Data analyzed was from a longitudinal cohort of preterm infants (n = 51) born at early, mid, and term GA of < 29, 29-33, and ≥ 37 weeks, respectively. Weekly EGG monitoring was performed until 40 weeks' postmenstrual age or discharge. Pre-, during, and post-feed data were analyzed for mPSD_GR at each GR band. Also, % bradygastria, % normogastria, and % tachygastria were calculated by continuous wavelet transform analysis. Results showed (1) mPSD values in normogastria and tachygastria during feeding increased with advancing GA, and (2) % normogastria increased with advancing GA regardless of GR ranges, suggesting EGG may measure GI maturity in preterm infants.

Early life nutrition and brain development: breakthroughs, challenges and new horizons

The role of early life nutrition's impact on relevant health outcomes across the lifespan laid the foundation for the field titled the developmental origins of health and disease. Studies in this area initially concentrated on nutrition and the risk of adverse cardio-metabolic and cancer outcomes. More recently the role of nutrition in early brain development and the subsequent influence of later mental health has become more evident. Scientific breakthroughs have elucidated two mechanisms behind long-term nutrient effects on the brain, including the existence of critical periods for certain nutrients during brain development and nutrient-driven epigenetic modifications of chromatin. While multiple nutrients and nutritional conditions have the potential to modify brain development, iron can serve as a paradigm to understand both mechanisms. New horizons in nutritional medicine include leveraging the mechanistic knowledge of nutrient-brain interactions to propose novel nutritional approaches that protect the developing brain through better timing of nutrient delivery and potential reversal of negative epigenetic marks. The main challenge in the field is detecting whether a change in nutritional status truly affects the brain's development and performance in human subjects. To that end, a strong case can be made to develop and utilise bioindicators of a nutrient's effect on the developing brain instead of relying exclusively on biomarkers of the nutrient's status.

Clinical Observation of Extensively Hydrolysis Protein Formula With Feeding Intolerance in Preterm Infants

Objective

To investigate whether feeding extensively hydrolysis protein formula during the NICU hospitalization was more beneficial for preterm infants with a gestational age (GA) ≤34 weeks when breastfeeding was not possible.

Methods

In total, 587 preterm infants were randomly divided into two groups: observation groups fed with extensively hydrolyzed formula (EHF) milk and control groups fed with standard preterm formula (SPF) milk until discharge from the neonatal intensive care unit (NICU). The incidence of complications during hospitalization was recorded in both groups. Then, two groups were uniformly fed with 0-to-6-month infant formula milk and followed-up for 6 months after discharge.

Results

The final study included 370 premature infants, including 185 babies in the observation group and 185 in the control group. In contrast to the SPF, feeding EHF among preterm infants of GA <34 weeks during NICU hospitalization significantly reduced the incidence of feeding intolerance (FI) (14.1 vs. 30.3%, p < 0.01). The incidence of necrotizing enterocolitis (NEC) was significantly reduced in the observation group (2.2 vs. 6.5%, p < 0.05), but there was no significant difference in the incidence of other related complications. At discharge, there was no difference in total serum protein (46.6 vs. 46.4 g/L), albumin (33.5 vs. 34.2 g/L), and calcium (2.37 vs. 2.35 mmol/L), but the serum phosphorus concentrations associated with skeletal mineralization (2.10 vs. 2.22 mmol/L, p < 0.05) was significantly reduced and alkaline phosphatase significantly rose (254 vs. 220 IU/L, p < 0.05) in the observation group. No significant difference was found in the growth rates of body weight, head circumference, or body length, either during the NICU hospitalization or during the 6-month follow-up after discharge (p > 0.05).

Conclusions

Feeding premature infants of GA ≤34 weeks with EHF reduced the incidence of FI, but had no advantage in establishing whole intestinal nutrition, shortening parenteral nutrition (PN) time, or hospitalization time. It had little effect on physical growth or development during NICU hospitalization and within 6 months after discharge. However, it may increase the incidence of metabolic bone disease (MBD).

Body composition of extremely preterm infants fed protein-enriched, fortified milk: a randomized trial

BACKGROUND

Critically ill extremely preterm infants fed human milk are often underrepresented in neonatal nutrition trials aimed to determine the effects of enteral protein supplementation on body composition outcomes.

METHODS

Masked randomized trial in which 56 extremely preterm infants 25-28 weeks of gestation were randomized to receive either fortified milk enriched with a fixed amount of extensively hydrolyzed protein (high protein group) or fortified milk without additional protein (standard protein group).

RESULTS

Baseline characteristics were similar between groups. In a longitudinal analysis, the mean percent body fat (%BF) at 30-32 weeks of postmenstrual age (PMA), 36 weeks PMA, and 3 months of corrected age (CA) did not differ between groups (17 ± 3 vs. 15 ± 4; p = 0.09). The high protein group had higher weight (-0.1 ± 1.2 vs. -0.8 ± 1.3; p = 0.03) and length (-0.8 ± 1.3 vs. -1.5 ± 1.3; p = 0.02) z scores from birth to 3 months CA. The high protein group also had higher fat-free mass (FFM) z scores at 36 weeks PMA (-0.9 ± 1.1 vs. -1.5 ± 1.1; p = 0.04).

CONCLUSIONS

Increased enteral intake of protein increased FFM accretion, weight, and length in extremely preterm infants receiving protein-enriched, fortified human milk.

IMPACT

Extremely preterm infants are at high risk of developing postnatal growth failure, particularly when they have low fat-free mass gains. Protein supplementation increases fat-free mass accretion in infants, but several neonatal nutrition trials aimed to determine the effects of enteral protein supplementation on body composition outcomes have systematically excluded critically ill extremely preterm infants fed human milk exclusively. In extremely preterm infants fed fortified human milk, higher enteral protein intake increases fat-free mass accretion and promotes growth without causing excessive body fat accretion.

Pasteurised donor human milk audit: What is happening in the neonatal critical care unit?

AIM

Human milk with fortification, providing additional energy, protein and micronutrients, is considered the optimal form of nutrition for preterm infants as it provides protection against infections and improves outcomes. Mothers' own milk (MOM) is the preferred choice, however in situations where MOM is insufficient or contraindicated; Pasteurised donor human milk (PDHM) is the preferred alternative. This study aimed to identify whether PDHM during neonatal critical care unit (NCCU) admission is associated with discharge nutrition in preterm infants.

METHODS

A retrospective observational cohort study was conducted over a 12-month period in 2017. This included all inborn infants admitted to the NCCU with gestational age ≤ 28 weeks or ≤ 1000 g birthweight, who survived until discharge. Multivariate logistic models were used to detect the association between study groups (PDHM vs. No PDHM) and discharge nutrition.

RESULTS

Seventy-seven infants were included; 35 infants received PDHM during admission. At discharge, infants who received PDHM were significantly more likely to be on infant formula (IF) (86%) than infants who did not receive PDHM (26%). In contrast, infants who did not receive PDHM (No PDHM) were significantly more likely to be receiving MOM exclusively at discharge (74%), than those who did receive PDHM (14%). The odds of an infant being discharged on IF were 16.91 times higher if they received PDHM.

CONCLUSION

In this study, infants born at ≤28 weeks or ≤ 1000 g who received PDHM were more likely to receive IF at NCCU discharge than infants who did not receive PDHM.

What are the new guidelines and position papers in pediatric nutrition: A 2015-2020 overview

BACKGROUND

Nutrition related publications in pediatric population cover wide range of topics and therefore it is usually difficult for clinicians to get an overview of recent nutrition related guidelines or recommendations.

METHODS

The Special Interest Group (SIG) of Pediatrics of European Society for Clinical Nutrition and Metabolism (ESPEN) performed a literature search to capture publications in the last five years aiming to provide the latest information concerning nutritional issues in children in general and in specific diseases and to discuss progression in the field of pediatric nutrition evidence-based practice.

RESULTS

Eight major topics were identified as the most frequently reported including allergy, critical illness, neonatal nutrition, parenteral and enteral nutrition, micronutrients, probiotics and malnutrition. Furthermore, it was noted that many reports were disease focused or included micronutrients and were, therefore, represented as tables.

CONCLUSION

Overall, it has been shown that most reports on nutrition topics in pediatrics were systematic reviews or guidelines/position papers of relevant societies, but many of them basing the conclusion on a limited number of high-quality randomized controlled trials or large observational cohort studies.

The Power of Networking and Lessons Learned From Omegaven

As more meetings become virtual, the impact of "live" meetings is being reevaluated. Here one example of how a chance meeting at a national pharmacy meeting led to the development of a new drug therapy that reinvented how parenteral nutrition is provided to infants and children is described. Along the way, many lessons were learned both in the lab and at home. Addressing the challenges raised by others, understanding how the FDA works, and the power of parental involvement are all considered. Until 2013, the only FDA-approved lipid emulsions were those composed of pure soybean oils. Starting with compassionate use protocol in 2004, it took 18 years and hundreds of patients to bring a pure fish oil lipid emulsion to the US market. First used off label to treat a soy-allergic patient dependent on parenteral nutrition, researchers at Boston Children's Hospital later conducted animal studies on its role in treating and preventing intestinal failure associated with liver injury and later translated it into clinical trials that led to the drug's approval in 2018. This is a recount of those efforts.

Gestational weight gain and body composition of full-term newborns and infants: a cohort study

Background

The association between gestational weight gain and neonatal body composition has been inconsistent, exposing the need for further research. The aim of this study was to evaluate whether gestational weight gain influences the body composition of full-term newborns and infants up to 4 months old.

Methods

A cohort study was performed with 124 participants divided into categories of gestational weight gain according to the 2009 Institute of Medicine guidelines. The anthropometric and body composition data of newborns and infants acquired using air displacement plethysmography (PeaPod®) were collected at 96 h, 1 month, 2 months and 4 months of life. In the statistical analysis, the chi-square test was used to analyze categorical variables, and ANOVA was used to analyze numerical variables. Univariate analysis was performed, and the absolute and relative frequencies of the categorical variables, as well as mean and standard deviation of the numerical variables, were obtained. Bivariate analysis was performed for the categories of gestational weight gain and gestational and neonatal characteristics. When adjustments to gestational hypertension, gestational diabetes, and pregestational body mass index (BMI) were analyzed by linear regression, gestational weight gain remained a significant variable for newborn percent fat mass. For all analyses, a significance level of 5% was adopted.

Results

Gestational weight gain was adequate in 33.8% of the participants, excessive in 41.1% and insufficient in 25%. Women with excessive weight gain had higher pregestational BMIs and a higher incidence of gestational hypertension. Their newborns had a higher body mass, body fat mass in grams and percent fat mass than the infants born to mothers with adequate or insufficient gestational weight gain. No significant differences were observed in body composition at 1, 2 and 4 months of life during infant follow-up.

Conclusion

Excessive gestational weight gain may alter the body composition of newborns at birth. Further studies are required to better evaluate infant follow-up.

Trial registration

Clinical Trial Registry: NCT00875251 on April 3, 2009.

MACRONUTRIENTS OF MOTHERS' MILK OF VERY LOW BIRTH WEIGHT INFANTS: ANALYSIS ACCORDING TO GESTATIONAL AGE AND MATERNAL VARIABLES

Objective:

To analyze the composition of macronutrients present in the milk of mothers of preterm newborn infants (PTNB) - protein, fat, carbohydrate, and calories - by gestational age (GA), chronological age (CA) and maternal variables.

Methods:

Longitudinal study that analyzed 215 milk samples from the 51 mothers of PTNB admitted in three Neonatal Intensive Care Units of Rio de Janeiro from May/2013-January/2014. Milk collection was performed by pickup pump, on a fixed day of each week until discharge. The spectrophotometric technique with Infrared Analysis (MilkoScan Minor 104) was used for the quantitative analysis. A sample of 7 mL of human milk was taken from the total volume of milk extracted by the mother. The data was grouped by GA (25-27, 28-31, 32-36, 37-40 weeks) and by CA (zero to 4, 5-8, 9-12, 13-16 weeks).

Results:

Protein, carbohydrate, fat and calories did not show any pattern of change, with no difference among groups of GA. When the macronutrients were analyzed by groups of CA, protein decreased, with significant difference between the first two groups of CA. Carbohydrates, fat and calories presented increasing values in all groups, without significant differences. Weight gain during pregnancy, maternal hypertension and maternal age were associated with changes in fat and calories in the first moment of the analysis of milk.

Conclusions:

There was a significant decrease in the levels of protein during the first eight weeks after birth. CA may be an important factor in the composition of human milk.

Adequacy of Parenteral Nutrition in Preterm Infants According to Current Recommendations: A Study in A Spanish Hospital

Background: In preterm infants, it is important to ensure adequate nutritional intake to accomplish foetal growth requirements. This study evaluated clinical practice regarding the prescription of parenteral nutrition in preterm infants in the neonatology unit of a tertiary hospital. Methods: It was a retrospective observational study of a sample of preterm infants (n = 155) born between January 2015 and December 2017 who were prescribed parenteral nutrition. Compliance with the hospital’s protocol and with the guidelines of the scientific societies American Society for Parenteral and Enteral Nutrition (ASPEN), European Society for Clinical Nutrition and Metabolism (ESPEN) and Spanish Society of Clinical Nutrition and Metabolism (SENPE) was evaluated. The differences in macronutrient intake and total duration of parenteral nutrition were analysed according to gestational age and birth weight. Results: The established protocol was followed in a high percentage (95.5%–100%) except with respect to the initiation of supplying established trace elements (64.9%). Compliance with the recommendations set forth in the guidelines was between 82.1% and 100%, with the exception of the initial carbohydrate intake recommended by ASPEN and ESPEN, for which compliance was 8.3%. Lower gestational age and birth weight were correlated with longer duration of parenteral nutrition (p < 0.001). Conclusions: A lower gestational age and birth weight are related to a longer duration of parenteral nutrition. The results of this study demonstrate the importance of developing and evaluating protocols in clinical practice.

Intrauterine Growth Restriction: New Insight from the Metabolomic Approach

Recognizing intrauterine growth restriction (IUGR) is a matter of great concern because this condition can significantly affect the newborn's short- and long-term health. Ever since the first suggestion of the "thrifty phenotype hypothesis" in the last decade of the 20th century, a number of studies have confirmed the association between low birth weight and cardiometabolic syndrome later in life. During intrauterine life, the growth-restricted fetus makes a number of hemodynamic, metabolic, and hormonal adjustments to cope with the adverse uterine environment, and these changes may become permanent and irreversible. Despite advances in our knowledge of IUGR newborns, biomarkers capable of identifying this condition early on, and stratifying its severity both pre- and postnatally, are still lacking. We are also still unsure about these babies' trajectory of postnatal growth and their specific nutritional requirements with a view to preventing, or at least limiting, long-term complications. In this setting, untargeted metabolomics-a relatively new field of '-omics' research-can be a good way to investigate the metabolic perturbations typically associated with IUGR. The aim of this narrative review is to provide a general overview of the pathophysiological and clinical aspects of IUGR, focusing on evidence emerging from metabolomic studies. Though still only preliminary, the reports emerging so far suggest an "early" pattern of glucose intolerance, insulin resistance, catabolite accumulation, and altered amino acid metabolism in IUGR neonates. Further, larger studies are needed to confirm these results and judge their applicability to clinical practice.

An Intergenerational Approach to Break the Cycle of Malnutrition

PURPOSE OF REVIEW

This article examines how nutritional status is treated throughout the lifecycle. In doing so, the review identifies promising life stages during which intervention may improve nutritional status of future generations.

RECENT FINDINGS

A life course perspective suggests that nutritional changes are most likely to be sustained when they occur during times of developmental transition, such as pregnancy or adolescence. Adolescence is a unique period in which malnutrition in future generations may be addressed because it is the first life stage at which pregnancy becomes feasible and individuals seek independence from parents. A need exists to begin investigating not just how nutrition changes are sustained throughout the lifespan, but how nutritional intervention in one generation impacts the next. This intergenerational approach should be undertaken with cross-discipline collaboration to have the best chance at impacting underlying determinants of malnutrition like poverty and women's education.

Preterm newborn's postnatal growth patterns: how to evaluate them

OBJECTIVES

There are several factors that influence the postnatal growth of preterm infants. It is crucial to define how to evaluate the growth rate of each preterm child and its individual trajectory, the type of growth curve, either with parameters of prescriptive curves for healthy preterm infants with no morbidities or, in the case of preterm infants and their "bundle of vulnerabilities", growth curves that may represent how they are actually growing, with the aim of directing appropriate nutritional care to each gestational age range.

DATA SOURCES

The main studies with growth curves for growth monitoring and the appropriate nutritional adjustments that prioritized the individual trajectory of postnatal growth rate were reviewed. PubMed and Google Scholar were searched.

DATA SYNTHESIS

The use of longitudinal neonatal data with different gestational ages and considering high and medium-risk pregnancies will probably be essential to evaluate the optimal growth pattern.

CONCLUSIONS

Prioritizing and knowing the individual growth trajectory of each preterm child is an alternative for preterm infants with less than 33 weeks of gestational age. For larger preterm infants born at gestational age >33 weeks, the Intergrowth 21st curves are adequate.

The Pregnancy and Birth to 24 Months Project: a series of systematic reviews on diet and health

Nutrition exposures during the earliest stages of life are integral to growth and development and may continue to affect health through adulthood. The purpose of the Pregnancy and Birth to 24 Months (P/B-24) Project was to conduct a series of systematic reviews on diet and health for women who are pregnant and for infants and toddlers from birth to 24 mo of age. The P/B-24 Project was a joint initiative led by the USDA and the US Department of Health and Human Services. The USDA's Nutrition Evidence Systematic Review team, previously known as the Nutrition Evidence Library, carried out the series of systematic reviews in collaboration with programmatic and scientific experts. Systematic review questions were prioritized based on federal policy, program, or guidance needs, potential to support the development of healthy dietary intake, and public health importance. Systematic reviews were conducted on specific topics related to dietary intake before and during pregnancy, infant milk feeding practices, complementary feeding, flavor exposures, and infant/toddler feeding practices. Across the reviews, relationships were observed between P/B-24 diet exposures and a variety of outcomes of public health importance. Evidence showed links between dietary intake before and during pregnancy, during the period of human milk or infant formula feeding, and through introduction of complementary foods and beverages and health outcomes. Additionally, the reviews on flavor exposure and infant/toddler feeding practices highlight the importance of maternal diet during pregnancy and lactation and caregiver feeding strategies and practices. Systematic reviews are an important tool to inform our understanding of the body of evidence related to diet and health, and scientists can use the P/B-24 Project reviews to continue to advance research in these areas.

Turkish Neonatal Society guideline on parenteral nutrition in preterm infants

Postnatal growth failure due to inappropriate and insufficient nutrition is a risk for preterm infants, especially for very-low-birth-weight or extremely-low-birth-weight infants. This extrauterine growth failure causes negative effects on long-term neurodevelopment. Early initiation of intensive parenteral nutrition with appropriate protein and energy supply is a nutritional emergency when enteral feeding cannot be achieved. This approach prevents protein catabolism and helps achievement of positive protein balance and postnatal growth. Protein, lipid, and glucose initiation with appropriate doses that reach timely goals constitute the major elements of parenteral nutrition. The transition to enteral nutrition with the mother's milk at the earliest convenience must be targeted in parenteral nutrition.

Valid serial length measurements in preterm infants permit characterization of growth patterns

BACKGROUND

The lack of a valid and safe method for measuring length in critically ill preterm neonates has led to a primary focus on weight gain.

LOCAL PROBLEM

Paucity of valid length measurements, precluding the accurate analysis of growth patterns.

METHODS

Quality improvement project among infants < 29 weeks or small for gestational age < 35 weeks with embedded validation of (1) a caliper (infantometer) for length measurements and (2) length measurements during the first week to estimate birth length.

INTERVENTION

Implementation of valid methods to measure length.

RESULTS

We validated infantometer measurements and first week length measurements. The percentage of neonates with valid measurements during the first week rose from 10% to 78%, resulting in increased identification of classifiable growth patterns from < 10% to 89%.

CONCLUSIONS

By increasing the percentage of neonates with valid length measurements in the first week postnatal, we identified an increased number of neonates with classifiable growth abnormalities.

Body composition in preterm infants with intrauterine growth restriction: a cohort study

Aims:

The comparison of body composition parameters between the small for gestational age (SGA) and appropriate for gestational age (AGA) at term, 1, 3 and 5 months corrected ages in very preterm infants.

Methods:

This cohort study included 92 preterm infants at term age, younger than 32 weeks or <1500 g, classified in two groups: SGA and AGA. Anthropometry and body composition, estimated by air displacement plethysmography, were evaluated at the corrected ages: term and 1, 3, and 5 months. We used the lean mass/fat mass index (LM/FM) at each time point and the weight, length and head circumference SDS gain between the time points.

Results:

At term age, the SGA preterm infants had less lean mass (g), fat mass (g) and percent fat mass but a greater LM/FM index than AGA infants (P<0.001). At 1 month corrected age the LM/FM index and percent fat mass between the groups became similar. Lower lean mass persisted up to 3 months in the SGA group [4004 g (3256–4595) vs. 4432 g (3190–6246), P<0.001]. During the first month corrected age, the weight SDS gain was higher in SGA preterm infants when compared to AGA preterm infants. However, the SGA preterm infants remained lighter, shorter and with smaller head circumferences than the AGA preterm infants until 3 months of corrected age.

Conclusions:

The greater lean tissue deficits and an earlier “catch-up” in fat in the SGA group can reflect growth patterns variability since the early life.

Nutritional influences on brain development

There is increasing evidence from preclinical and human studies that nutrition in the late foetal and early neonatal period has a significant impact on neurodevelopment across the lifespan. Certain nutrients have particularly large effects in this time period, and their deficits cause greater long-term risk. The mechanisms by which nutrients influence early brain growth and the sensitive periods for when certain nutrients should be provided are being elucidated. Assessments of nutritional status that index brain growth and predict long-term development are important to assess the efficacy of early life nutritional therapies.

CONCLUSION

Optimizing nutrition during foetal and early postnatal life is a golden opportunity to impact neurodevelopment and brain function across the lifespan.

Improving Growth for Infants ≤1250 Grams Receiving an Exclusive Human Milk Diet

BACKGROUND

An exclusive human milk diet (EHM) fortified with human milk-based fortifier decreases necrotizing enterocolitis (NEC) compared to maternal milk supplemented with preterm formula and bovine fortifier (PTF). Growth has been less with EHM and also maternal milk supplemented with donor human milk and bovine fortifier (HMBF). The objective was to evaluate the effect of a standardized feeding protocol on the growth of infants ≤1250 g birth weight supported with EHM and HMBF. The effect on the incidence of NEC was also evaluated.

DESIGN/METHODS

A retrospective study of growth before and after implementation of a feeding protocol for infants who received either EHM or HMBF. Primary outcomes were weight, length, and head circumference gain velocities from birth to discharge. The incidence of NEC was also recorded.

RESULTS

Analysis of covariance for 379 total infants showed that earlier day of life for fortification to 24 Kcal/oz was associated with increased weight gain (p = 0.0166) and length gain (p = 0.0064). Implementation of the feeding protocol was associated with increased head circumference gain (p = 0.006). EHM was associated with decreased incidence of NEC (p = 0.0302).

CONCLUSIONS

Implementation of a standardized feeding protocol including earlier fortification of maternal milk was associated with improved growth for infants receiving human milk feedings. EHM significantly decreased NEC. Earlier fortification had no effect on NEC.

Nutrition Practices and Predictors of Postnatal Growth in Preterm Infants During Hospitalization: A Longitudinal Study

Premature infants are at high risk of undernutrition and extrauterine growth restriction.

AIM

The aim of the study was to evaluate the relation between nutrition practices and growth rate in preterm infants from birth to 36 weeks postmenstrual age (PMA).

METHODS

Longitudinal data were collected retrospectively in 103 infants born <33 weeks gestation admitted to Dunedin Neonatal Intensive Care Unit, New Zealand. Weight, length, and head circumference at birth and 36 weeks PMA z scores were calculated using the INTERGROWTH Preterm Growth Standard. Growth velocity (g · kg · day) was determined via exponential model. Time to regain birth weight and nutritional practices including enteral nutrition, withholding feeds, nutrient intake, and feeding at discharge were described. Regression was used to explore associations between growth and nutritional variables.

RESULTS

Growth faltering (weight-for-age z score <-1.28/10th centile) increased from 9% at birth to 19% at 36 weeks PMA. Mean (standard deviation) growth velocity in-hospital (14.2 [3.3] g · kg · day) was well below the desirable rate of 18 g · kg · day. Forty-one percent of infants had feeds withheld, which was significantly associated with a longer time period to achieve full enteral feedings (P < 0.001) and poorer weight and length z score at 36 weeks PMA (both P < 0.05). The day of life to establish full enteral feedings was longer than recommended yet positively associated with weight at 36 weeks PMA (P = 0.019), whereas controlling for withholding feeds and other known confounders.

CONCLUSIONS

Extrauterine growth restriction was highly prevalent in this population. The negative association of withholding of feeds on growth reinforces the need to evaluate early life feeding protocols and further assess the longer-term influence of this practice on postdischarge growth outcomes.

Advances in nutrition of the newborn infant

Nutrition of newborn infants, particularly of those born preterm, has advanced substantially in recent years. Extremely preterm infants have high nutrient demands that are challenging to meet, such that growth faltering is common. Inadequate growth is associated with poor neurodevelopmental outcomes, and although improved early growth is associated with better cognitive outcomes, there might be a trade-off in terms of worse metabolic outcomes, although the contribution of early nutrition to these associations is not established. New developments include recommendations to increase protein supply, improve formulations of parenteral lipids, and provide mineral supplements while encouraging human milk feeding. However, high quality evidence of the risks and benefits of these developments is lacking. Clinical trials are also needed to assess the effect on preterm infants of experiencing the smell and taste of milk, to determine whether boys and girls should be fed differently, and to test effects of insulin and IGF-1 supplements on growth and developmental outcomes. Moderate-to-late preterm infants have neonatal nutritional challenges that are similar to those infants born at earlier gestations, but even less high quality evidence exists upon which to base clinical decisions. The focus of research in nutrition of infants born at term is largely directed at new formula products that will improve cognitive and metabolic outcomes. Providing the most effective nutrition to preterm infants should be prioritised as an important focus of neonatal care research to improve long-term metabolic and developmental outcomes.

Preterm Infant Growth Velocity Calculations: A Systematic Review

CONTEXT

Clinicians assess the growth of preterm infants and compare growth velocity using a variety of methods.

OBJECTIVE

We determined the numerical methods used to describe weight, length, and head circumference growth velocity in preterm infants; these methods include grams/kilogram/day (g/kg/d), grams/day (g/d), centimeters/week (cm/week), and change in z scores.

DATA SOURCES

A search was conducted in April 2015 of the Medline database by using PubMed for studies that measured growth as a main outcome in preterm neonates between birth and hospital discharge and/or 40 weeks' postmenstrual age. English, French, German, and Spanish articles were included. The systematic review was conducted by using Preferred Reporting Items for Systematic Reviews and Meta-analyses methods.

STUDY SELECTION

Of 1543 located studies, 373 (24%) calculated growth velocity.

DATA EXTRACTION

We conducted detailed extraction of the 151 studies that reported g/kg/d weight gain velocity.

RESULTS

A variety of methods were used. The most frequently used method to calculate weight gain velocity reported in the 1543 studies was g/kg/d (40%), followed by g/d (32%); 29% reported change in z score relative to an intrauterine or growth chart. In the g/kg/d studies, 39% began g/kg/d calculations at birth/admission, 20% at the start of the study, 10% at full feedings, and 7% after birth weight regained. The kilogram denominator was not reported for 62%. Of the studies that did report the denominators, the majority used an average of the start and end weights as the denominator (36%) followed by exponential methods (23%); less frequently used denominators included birth weight (10%) and an early weight that was not birth weight (16%). Nineteen percent (67 of 355 studies) made conclusions regarding extrauterine growth restriction or postnatal growth failure. Temporal trends in head circumference growth and length gain changed from predominantly cm/wk to predominantly z scores.

LIMITATIONS AND CONCLUSIONS

The lack of standardization of methods used to calculate preterm infant growth velocity makes comparisons between studies difficult and presents an obstacle to using research results to guide clinical practice.

Executive summary: evaluation of the evidence to support practice guidelines for nutritional care of preterm infants-the Pre-B Project

Preterm birth (infants born at <37 wk of gestational age) is a significant clinical and public health challenge in the United States and globally. No universally accepted practice guidelines exist for the nutritional care of preterm infants. To address the current state of knowledge and to support systematic reviews that will be used to develop evidence-informed guidance, a consortium consisting of the American Academy of Pediatrics, the ASN, the American Society for Parenteral and Enteral Nutrition, the Academy of Nutrition and Dietetics, the Food and Drug Administration, the CDC, the USDA/Agricultural Research Service (USDA/ARS), and the Eunice Kennedy Shriver National Institute of Child Health and Human Development/NIH initiated the Pre-B Project. The project included the constitution of 4 thematic working groups charged with the following tasks: 1) develop a series of topics/questions for which there is sufficient evidence to support a systematic review process to be conducted by the Academy of Nutrition and Dietetics' Evidence Analysis Library (EAL), leading to the development of new guidelines for nutritional care of preterm infants, and 2) develop a targeted research agenda to address priority gaps in our understanding of the role of nutrition in the health and development of preterm/neonatal intensive care unit infants. This review consists of a project overview including a summary of a workshop hosted by the USDA/ARS Children's Nutrition Research Center and summary reports of the 4 working groups established to address the following themes: 1) nutrient specifications, 2) clinical/practical issues in enteral feeding, 3) gastrointestinal and surgical issues, and 4) current standards for assessing infant feeding outcomes. These reports will serve as the basis for the ultimate guideline development process to be conducted by the Academy of Nutrition and Dietetics' EAL.