Follow-up of a randomized trial on postdischarge nutrition in preterm-born children at age 8 y

Clinical Phenotypes of Malnutrition in Young Children: Differential Nutritional Correction

This review article summarizes current data on malnutrition etiology and pathogenesis in infants. Topical requirements for revealing this condition, its diagnosis and severity assessment via centile metrics are presented. The characteristics of the most common clinical phenotypes of postnatal growth insufficiency in infants (premature infants with different degree of maturation, including patients with bronchopulmonary dysplasia) are described. Differential approaches for malnutrition nutritional correction in these children are presented. The final section of the article describes special nutritional needs for children with congenital heart defects in terms of hemodynamic disorders nature and severity. Modern nutritional strategies for preparation of these patients to surgery and for their postoperative period are presented. The use of high-calorie/high-protein product for malnutrition correction in the most vulnerable patients with described in this review phenotypes is worth noticing.

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.

Mother's Own Milk Compared With Formula Milk for Feeding Preterm or Low Birth Weight Infants: Systematic Review and Meta-analysis

OBJECTIVES

We assessed the effect of feeding preterm or low birth weight infants with infant formula compared with mother's own milk on mortality, morbidity, growth, neurodevelopment, and disability.

METHODS

We searched Medline (Ovid), Embase (Ovid), and Cochrane Central Register of Controlled Studies to October 1, 2021.

RESULTS

Forty-two studies enrolling 89 638 infants fulfilled the inclusion criteria. We did not find evidence of an effect on mortality (odds ratio [OR] 1.26, 95% confidence interval [CI] 0.91-1.76), infection (OR 1.52, 95% CI 0.98-2.37), cognitive neurodevelopment (standardized mean difference -1.30, 95% CI -3.53 to 0.93), or on growth parameters. Formula milk feeding increased the risk of necrotizing enterocolitis (OR 2.99, 95% CI 1.75-5.11). The Grading of Recommendations Assessment, Development, and Evaluation certainty of evidence was low for mortality and necrotizing enterocolitis, and very low for neurodevelopment and growth outcomes.

CONCLUSIONS

In preterm and low birth weight infants, low to very low-certainty evidence indicates that feeding with infant formula compared with mother's own milk has little effect on all-cause mortality, infection, growth, or neurodevelopment, and a higher risk of developing necrotizing enterocolitis.

Improving long-term health outcomes of preterm infants: how to implement the findings of nutritional intervention studies into daily clinical practice

Preterm-born children are at risk for later neurodevelopmental problems and cardiometabolic diseases; early-life growth restriction and suboptimal neonatal nutrition have been recognized as risk factors. Prevention of these long-term sequelae has been the focus of intervention studies. High supplies of protein and energy during the first weeks of life (i.e., energy > 100 kcal kg-1 day-1 and a protein-to-energy ratio > 3 g/100 kcal) were found to improve both early growth and later neurodevelopmental outcome. Discontinuation of this high-energy diet is advised beyond 32-34 weeks postconceptional age to prevent excess fat mass and possible later cardiometabolic diseases. After discharge, nutrition with a higher protein-to-energy ratio (i.e., > 2.5-3.0 g/100 kcal) may improve growth and body composition in the short term.Conclusion: Preterm infants in their first weeks of life require a high-protein high-energy diet, starting shortly after birth. Subsequent adjustments in nutritional composition, aimed at achieving optimal body composition and minimizing the long-term cardiometabolic risks without jeopardizing the developing brain, should be guided by the growth pattern. The long-term impact of this strategy needs to be studied. What is Known: • Preterm infants are at risk for nutritional deficiencies and extrauterine growth restriction. • Extrauterine growth restriction and suboptimal nutrition are risk factors for neurodevelopmental problems and cardiometabolic disease in later life. What is New: • Postnatally, a shorter duration of high-energy nutrition may prevent excess fat mass accretion and its associated cardiometabolic risks and an early switch to a protein-enriched diet should be considered from 32-34 weeks postconceptional age. • In case of formula feeding, re-evaluate the need for the continuation of a protein-enriched diet, based on the infant's growth pattern.

Mineral and nutritional requirements of preterm infant

Preterm infants are at risk of growth failure and metabolic bone disease due to insufficient nutrient supply in postnatal life. An ample provision of protein, energy, calcium and phosphates through parenteral or/and enteral nutrition is crucial for bone growth and mineralization. Additional vitamin D supplementation improves bone mineralization and enhance intestinal absorption of minerals.

Early-life growth of preterm infants and its impact on neurodevelopment

BACKGROUND

Increasing numbers of preterm-born children survive nowadays, and improving long-term health and neurodevelopment is becoming more important. Early-life growth has been linked to neurodevelopmental outcomes. We aimed to study whether this association has changed with time.

METHODS

We studied two cohorts of preterm-born children (gestational age ≤32 weeks and/or birth weight ≤1500 g) from 1983 (n = 708) and 2003-2006 (n = 138), respectively. We distinguished four early-life growth patterns at 3 months corrected age: appropriate for gestational age (AGA) with or without growth restriction (AGA GR+/AGA GR-), and small for gestational age (SGA) with or without catch-up growth (SGA CUG+/SGA CUG-). Intelligence quotient (IQ), neuromotor function, and behavior were assessed at ages 19 and 8 years, respectively, for the cohorts.

RESULTS

In the 2003-2006 cohort, less children had early-life GR. In both cohorts, SGA CUG- subjects had unfavorable growth trajectories and neurodevelopmental outcomes (IQ β -6.5, 95% confidence interval (CI) -9.8; -3.2, P < 0.001; neuromotor score β -1.9%, 95% CI -3.2; -0.6, P = 0.005), while SGA CUG+ subjects were comparable to adequately grown subjects.

CONCLUSION

Although the incidence of adverse growth patterns decreased between the cohorts, possibly indicating improvements in care over time, the impact of these growth patterns on neurodevelopmental outcomes was not significantly different. Achieving adequate early-life growth may be crucial for improving neurodevelopmental outcomes, especially for preterms born SGA.

Measuring body composition in the preterm infant: Evidence base and practicalities

Preterm birth and body composition have demonstrable effects on growth and later health outcomes. Preterm infants reach term equivalent age with a lower proportion of lean mass and higher body fat percentage than their term equivalent counterparts. Weight and length do not give an accurate assessment of body composition. Tracking body composition rather than just weight is a fundamental part of improving nutritional outcomes. This is important given the ongoing controversies regarding the nutritional needs of preterm infants, as well as establishing suitable targets for their growth. In this review we describe current methodologies used in the measurement of body composition of the preterm infant and the review the recent published evidence for their accuracy and utility. Current measurement techniques employed include air displacement plethysmography, bioelectrical impedance analysis, isotope dilution techniques, MRI and a combination of manual measurements including skinfold thickness, body mass index and mid upper arm/mid-thigh circumference. These measures allow for the estimation of fat mass, fat-free mass and regional assessment of adiposity. Some methods, such as dual-energy X-ray absorptiometry and air displacement plethysmography do allow for comparison of change in body composition over time in cohorts of preterm infants that may be studied over a longer period of time and into adult life. However, none of the currently described methods give an accurate and practically achievable method of obtaining body composition measures in preterm infants in day to day routine clinical practise, although this remains a key priority when decisions are being made about how best to feed.

Neurodevelopment of children born very preterm and/or with a very low birth weight: 8-Year follow-up of a nutritional RCT

BACKGROUND

Children born very preterm are at risk for cognitive deficits and motor impairment. Enhanced protein intake immediately after very preterm birth has been associated with favorable growth and improved neurodevelopment. It is unknown whether increased protein intake after discharge from the hospital affects long-term neurodevelopment.

OBJECTIVE

The primary objective was to assess neurodevelopment from infancy to 8 years in preterm-born children who received either protein-enriched formula (PDF), standard term formula (TF), or human milk (HM) after discharge. The secondary objective was to assess the correlation between outcomes obtained at 24 months corrected age (CA) and at 8 years.

METHODS

This RCT included 152 children born very preterm (gestational age ≤32 weeks) and/or with a very low birth weight (≤1500 g) of whom 102 were randomly assigned to receive PDF (n = 54) or TF (n = 48) from term age to 6 months CA. A control group of infants fed HM (n = 50) was also included. Neurodevelopmental outcomes were assessed at 24 months CA (cognitive and motor functioning; n = 123) and at 8 years (estimated Full Scale Intelligence Quotient, visual-motor skills, verbal memory, attention, and motor functioning; n = 76).

RESULTS

The PDF and TF groups were not significantly different in neurodevelopmental outcomes. The HM group had a better cognitive score compared with the PDF group: at 24 months CA 92.9 ± 12.5 vs. 105.2 ± 18.6, P < 0.001 and at 8 years 98.1 ± 11.3 vs. 105.8 ± 9.1, P = 0.017 (P = 0.002 and P = 0.080, respectively, after adjustment for parental educational level). Correlations between outcomes at 24 months CA and 8 years were weak: r = 0.35 and r = 0.37 for cognitive and motor outcomes, respectively.

CONCLUSIONS

PDF did not improve long-term neurodevelopmental outcomes as compared with TF. However, these results should be interpreted with caution considering the substantial attrition at follow-up. Furthermore, the correlation between outcomes at different ages was weak, emphasizing the need for long-term follow-up of nutritional intervention studies in preterm-born children.

Leptin and IGF-1 in relation to body composition and bone mineralization of preterm-born children from infancy to 8 years

OBJECTIVE

Preterm birth has been associated with altered body composition, especially increased fat mass (FM) and decreased bone mineralization, and leptin and IGF-1 have been suggested to be involved in the regulation of both. We aimed to study the interplay between leptin, IGF-1, FM and bone mineralization measured in infancy and childhood of children born preterm.

DESIGN

Observational study.

PATIENTS/SUBJECTS

Seventy-nine (40 boys) preterm-born children (gestational age ≤32 weeks and/or birth weight ≤1500 g) aged 8 years.

MEASUREMENTS

Serum leptin and IGF-1 were measured at term age, at 3- and 6-month corrected age (CA), and 8 years. Body composition (fat and lean mass) and bone parameters (bone area, mineral content and density) were measured by Dual-energy X-ray Absorptiometry (DXA) at term age, 6-month CA and 8 years.

RESULTS

Leptin was positively associated with FM at all time points and with bone parameters at term age and 6-month CA. IGF-1 was associated with body composition and bone density at most of the time points. Explained variation in bone mineralization increased significantly by adding bone area (BA) and height to the models.

CONCLUSIONS

During infancy and childhood, leptin and IGF-1 were associated with body composition in preterm-born children. In addition, leptin was associated with bone parameters in early infancy, but not in childhood. It is hypothesized that a complicated interplay between multiple pathways, which most likely changes over time, is involved in regulation of body composition and bone mineralization of preterm-born infants.

Salt sensitivity of blood pressure at age 8 years in children born preterm

Preterm birth and low birth weight have been associated with an increased risk of hypertension; postnatal growth and dietary salt intake may contribute to these associations. In adults, the change of blood pressure (BP) in response to modifications in salt intake, i.e., salt sensitivity of BP, has been independently associated with cardiovascular disease. Little is known about salt sensitivity in children. We hypothesize that it may partly explain the association between preterm birth and higher BP in later life. We assessed salt sensitivity of BP at age 8 years in 63 preterm-born children, and explored its association with postnatal growth, sodium intake, and body composition from infancy onwards. BP was measured at baseline and after a 7-day high-salt diet. The difference in mean arterial pressure (MAP) was calculated; salt sensitivity was defined as an increase in MAP of ≥5%. Ten children (16%) showed salt sensitivity of BP, which was associated with neonatal growth restriction as well as with lower fat mass and BMI from infancy onwards. At age 8 years, children classified as salt sensitive had a lower weight-for-age SD-score (-1.5 ± 1.3 vs. -0.6 ± 1.1) and BMI (13.8 ± 1.7 vs. 15.5 ± 1.8 kg/m²) compared to their salt resistant counterparts. Sodium intake was not associated with (salt sensitivity of) BP. Salt sensitivity of BP was demonstrated in preterm-born children at age 8 years and may contribute to the development of cardiovascular disease at later age. Long-term follow-up studies are necessary to assess reproducibility of our findings and to explore clustering with other cardiovascular risk factors.

Effect of early nutritional intake on long-term growth and bone mineralization of former very low birth weight infants

BACKGROUND

Preterm infants are at risk for impaired bone mineralization and growth in length later in life due to inadequate nutritional intake in the early postnatal period.

OBJECTIVE

To investigate whether increased nutritional supplementation of calcium, phosphate and protein in Very Low Birth Weight (VLBW) infants during the first 14days after birth was associated with improvement in length and bone development until 9-10years of age.

DESIGN

Observational follow-up study of VLBW infants (birth weight<1500g or gestational age<32weeks) born in two consecutive years (eligible infants: 2004 n: 63 and 2005: n: 66). Cohort 2005 received higher intake of calcium, phosphate and protein with parenteral nutrition compared to Cohort 2004. Anthropometric data were collected during standard follow-up visits until five years, and additionally at 9-10years of age including measurements of bone mineral content, bone mineral density of the whole body and lumbar spine determined by dual-energy X-ray absorptiometry. Long-term growth trajectories of both cohorts were evaluated separately for participants born appropriate (AGA) and small for gestational age (SGA), stratified by gender. Multivariate linear regression was used to examine the effect of nutritional intake and clinical covariates on length and bone mineralization.

RESULTS

Both cohorts achieved a catch-up in length to SDS within the normal range by 6months (length SDS: estimated mean (95% confidence interval (CI): 6months: Cohort 2004: -0.7 (-1.1, -0.3) Cohort 2005: -0.5 (-0.8, -0.2)). Bone mineral content and density were within the normal range and not different between the cohorts. SGA children achieved a catch-up in length at 5years with bone mineralization comparable to AGA children. Only for girls birth weight was significantly associated with length SDS (per gram: β 0.001; 95% CI (0.000, 0.003); p=0.03) There was no evidence of an association between early nutritional intake and bone mineralization.

CONCLUSION

Children born as appropriate or small for gestational age preterm infants are able to catch up in length after the postnatal period, and achieve a normal length and bone mineralization at age nine-ten years. An improvement of calcium and phosphate intake during the first 14days after birth was not associated with improvement in length and bone development.

Anthropometry and Body Composition of Preterm Neonates in the Light of Metabolic Programming

The improved survival of preterm infants has led to increased interest regarding their health as adults. In the context of metabolic programming, the connection between perinatal and early postnatal nutrition and growth with health in later life has brought to the fore the role of catch-up growth during the first months of preterm infants' lives and its association with body fat and obesity in childhood or puberty. A state-of-the art review was conducted in order to assess the way catch-up is evaluated, in terms of timing and rate. Adequate growth is of major importance for neurodevelopment; however, it may compete with adiposity or metabolic health. Studies based on body composition assessment have given conflicting results as regards the effect of early versus late and rapid versus slow catch-up growth on later health, mainly attributed to the lack of established criteria and definitions. Given that adequate early nutrition is crucial for the neurodevelopment of preterm infants, further studies are needed on the role of catch-up growth in long-term outcome, using generally accepted qualitative and quantitative criteria.