Nutritional Support Strategies for the Preterm Infant in the Neonatal Intensive Care Unit

Growth and micronutrient status parameters of Nigerian preterm infants consuming preterm formula or breastmilk

BACKGROUND

Moderate-to-late preterm infants (32-34 weeks GA) have increased risk of neonatal morbidities compared to term infants, however dedicated nutritional guidelines are lacking.

METHODS

Moderate-to-late preterm infants received a preterm formula (n = 17) or breastmilk (n = 24) from age 2-10 weeks in a non-randomized, open-label observational study. Anthropometric measurements were assessed bi-weekly. Blood concentrations of hemoglobin, ferritin, serum retinol, and 25-hydroxy-vitamin D (25OHD) were analyzed at age 2 and 10 weeks.

RESULT

Average growth per day was 14.7 g/kg BW/day in formula-fed and 12.8 g/kg BW/day in breastmilk-fed infants but not different from each other. Length and head circumference in both groups were in line with the median reference values of the Fenton growth chart. At 10 weeks of age, hemoglobin tended to be higher in the formula-fed group (10.2 g/dL vs. 9.6 g/dL, p = 0.053). 25OHD increased in formula- and breastmilk-fed infants from 73.8 to 180.9 nmol/L and from 70.7 to 97.6 nmol/L, respectively. Serum retinol only increased in the formula-fed group (0.63 to 1.02 µmol/L, p < 0.001).

CONCLUSION

Breastfeeding resulted in adequate growth in moderate-late preterm infants but was limiting in some micronutrients. The preterm formula provided adequate micronutrients, but weight gain velocity was higher than the Fenton reference value.

IMPACT STATEMENT

Unfortified breastmilk resulted in adequate growth in weight, length and head circumference in Nigerian moderate to late preterm infants during an study period of 8 weeks, but status of vitamin D, vitamin A and iron needs to be monitored. The high-energy formula, developed for very preterm infants, resulted in higher growth in body weight in moderate to late preterm infants than the median of the Fenton preterm growth chart. This study supports the necessity of dedicated nutritional guidelines, and regular monitoring of growth and nutritional status of moderate to late preterm infants.

Difference in the Intestinal Microbiota between Breastfeed Infants and Infants Fed with Artificial Milk: A Systematic Review

The gut microbiota (GM) plays a crucial role in human health, particularly during the first years of life. Differences in GM between breastfed and formula (F)-fed infants may influence long-term health outcomes. This systematic review aims to compare the gut microbiota of breastfed infants with that of F-fed infants and to evaluate the clinical implications of these differences. We searched databases on Scopus, Web of Science, and Pubmed with the following keywords: "gut microbiota", "gut microbiome", and "neonatal milk". The inclusion criteria were articles relating to the analysis of the intestinal microbiome of newborns in relation to the type of nutrition, clinical studies or case series, excluding reviews, meta-analyses, animal models, and in vitro studies. The screening phase ended with the selection of 13 publications for this work. Breastfed infants showed higher levels of beneficial bacteria such as Bifidobacterium and Lactobacillus, while F-fed infants had a higher prevalence of potentially pathogenic bacteria, including Clostridium difficile and Enterobacteriaceae. Infant feeding type influences the composition of oral GM significantly. Breastfeeding promotes a healthier and more diverse microbial ecosystem, which may offer protective health benefits. Future research should explore strategies to improve the GM of F-fed infants and understand the long-term health implications.

The Association Between Prenatal Food Insecurity and Breastfeeding Initiation and Exclusive Breastfeeding Duration: A Longitudinal Study Using Oregon PRAMS and PRAMS-2, 2008-2015

Background: In the United States, 11.1% of households experience food insecurity; however, pregnant women are disproportionately affected. Maternal food insecurity may affect infant feeding practices, for example, through being a source of chronic stress that may alter the decision to initiate and continue breastfeeding. Thus, we sought to determine whether prenatal food insecurity was associated with breastfeeding (versus not) and exclusive breastfeeding duration among Oregon women. Method: The Oregon Pregnancy Risk Assessment Monitoring System (PRAMS) data of live births from 2008 to 2015 and the Oregon PRAMS-2 follow-up survey were used (n = 3,624) in this study. Associations with breastfeeding initiation and duration were modeled with multivariable logistic regression and accelerated failure time (AFT), respectively. Models were adjusted for maternal sociodemographic and pre-pregnancy health characteristics. Results: Nearly 10% of women experienced prenatal food insecurity. For breastfeeding initiation, unadjusted models suggested non-significant decreased odds (odds ratio (OR) 0.88 [confidence intervals (CI): 0.39, 1.99]), whereas adjusted models revealed a non-significant increased odds (OR 1.41 [CI: 0.58, 3.47]). Unadjusted AFT models suggested that food-insecure mothers had a non-significant decrease in exclusive breastfeeding duration (OR 0.76 [CI: 0.50, 1.17]), but adjustment for covariates attenuated results (OR 0.89 [CI: 0.57, 1.39]). Conclusions: Findings suggest minimal differences in breastfeeding practices when exploring food security status in the prenatal period, though the persistence of food insecurity may affect exclusive breastfeeding duration. Lower breastfeeding initiation may be due to other explanatory factors correlated with food insecurity and breastfeeding, such as education and marital status.

A clinical informatics approach to bronchopulmonary dysplasia: current barriers and future possibilities

Bronchopulmonary dysplasia (BPD) is a complex, multifactorial lung disease affecting preterm neonates that can result in long-term pulmonary and non-pulmonary complications. Current therapies mainly focus on symptom management after the development of BPD, indicating a need for innovative approaches to predict and identify neonates who would benefit most from targeted or earlier interventions. Clinical informatics, a subfield of biomedical informatics, is transforming healthcare by integrating computational methods with patient data to improve patient outcomes. The application of clinical informatics to develop and enhance clinical therapies for BPD presents opportunities by leveraging electronic health record data, applying machine learning algorithms, and implementing clinical decision support systems. This review highlights the current barriers and the future potential of clinical informatics in identifying clinically relevant BPD phenotypes and developing clinical decision support tools to improve the management of extremely preterm neonates developing or with established BPD. However, the full potential of clinical informatics in advancing our understanding of BPD with the goal of improving patient outcomes cannot be achieved unless we address current challenges such as data collection, storage, privacy, and inherent data bias.

Early versus late administration of amino acids in preterm infants receiving parenteral nutrition

BACKGROUND

Observational studies in preterm newborns suggest that delay in administering amino acids (AA) could result in a protein catabolic state and impact on growth and development.

OBJECTIVES

The objective of this review was to compare the efficacy and safety of early versus late administration of intravenous AA in neonates born at < 37 weeks of gestation.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and trial registries in March 2023. We checked the reference lists of included studies and studies/systematic reviews where subject matter related to the intervention or population examined in this review.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing early administration of AA with late administration in premature newborn infants. We defined early administration of AA solution as the administration of AA in isolation or with total parenteral nutrition within the first 24 hours of birth, and late administration as the administration of AA in isolation or with total parenteral nutrition after the first 24 hours of birth.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

Nine studies (383 participants) were eligible for inclusion in the review. All study participants were born at < 37 weeks of gestation and were inpatients in neonatal intensive care units. No studies reported growth during the first months of life as assessed by difference in weight. Early administration of AA may have little or no effect on growth in the first month of life as measured by length (mean difference (MD) 0.00, 95% confidence interval (CI) -0.41 to 0.41; 1 study; 21 participants; low-certainty evidence) and head circumference (MD 0.05, 95% CI -0.03 to 0.14; 2 studies; 87 participants; low-certainty evidence). No studies reported the discharge weight outcome. Early administration of AA may result in little to no difference in neurodevelopmental outcome assessed by Mental Developmental Index (MDI) of < 70 at two years of age (odds ratio 0.83, 95% CI 0.21 to 3.28; 1 study; 111 participants; low-certainty evidence). No studies reported all-cause mortality at 28 days and before discharge. Early administration of AA may result in a large increase in positive nitrogen balance in the first three days of life (MD 250.42, 95% CI 224.91 to 275.93; 4 studies; 93 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

Low-certainty evidence suggests that there may be little to no difference between early and late administration of AA in growth (measured by length and head circumference during the first month after birth) and neurodevelopmental outcome (assessed by MDI of < 70). No RCTs reported on weight in the first month of life, mortality (all-cause mortality at 28 days and before discharge), or discharge weight. Low-certainty evidence suggests a large increase in positive nitrogen balance in preterm infants who received AA within 24 hours of birth. The clinical relevance of this observation is unknown. The number of infants in the RCTs included in the review was small, and there was clinical heterogeneity amongst trials. Adequately powered trials in infants < 37 weeks' gestation are required to determine optimal timing of initiation of AA. We identified two ongoing studies. Both studies will be recruiting infants ≥ 34 weeks of gestation and may or may not add to the outcome data for this review.

Optimizing Nutrition in Neonates with Kidney Dysfunction

The nutritional management of neonates with kidney disease is complex. There may be significant differences in nutritional needs based on the duration and cause of kidney dysfunction, including acute kidney injury (AKI) and chronic kidney disease (CKD). Furthermore, the treatment modality, including acute (continuous renal replacement therapy and peritoneal dialysis [PD]) and chronic (intermittent hemodialysis and PD) approaches may differentially affect nutritional losses and dietary needs. In this review, we discuss the pathophysiology of compromised nutrition in neonates with AKI and CKD. We also summarize the existing data and consensus recommendations on the provision of nutrition to neonates with AKI and CKD. We highlight the paucity of data on micronutrient losses and the need for future prospective studies to enhance nutritional supplementation to hopefully improve outcomes in these patients.

The Prevalence of Small for Gestational Age and Extrauterine Growth Restriction among Extremely and Very Preterm Neonates, Using Different Growth Curves, and Its Association with Clinical and Nutritional Factors

Monitoring the growth of neonates in the Neonatal Intensive Care Unit (NICU) using growth charts constitutes an essential part of preterm infant care. Preterm infants are at increased risk for extrauterine growth restriction (EUGR) due to increased energy needs and clinical complications. This retrospective study compares the prevalence of small for gestational age (SGA) at birth and EUGR at discharge in extremely and very preterm neonates hospitalized in the NICU of a tertiary hospital in Greece, using different growth curves, and it examines the associated nutritional and clinical factors. Fenton2013 and INTERGROWTH-21st growth curves were used to calculate z-scores of birth weight (BW) and weight, length, and head circumference at discharge. The study includes 462 newborns with a mean BW of 1341.5 g and mean GA of 29.6 weeks. At birth, 6.3% of neonates were classified as SGA based on Fenton2013 curves compared to 9.3% with INTERGROWTH-21st growth curves. At discharge, 45.9% of neonates were characterized as having EUGR based on the Fenton2013 weight curves and 29.2% were characterized based οn INTERGROWTH-21st curves. Nutritional factors such as the day of initiation, attainment of full enteral feeding, and the duration of parenteral nutrition were associated with EUGR by both curves. The prevalence of SGA and EUGR neonates differs between the two growth references. This shows that further evaluation of these charts is needed to determine the most appropriate way to monitor infant growth.

Beyond survival: the lasting effects of premature birth

Preterm birth, defined as birth before 37 weeks of gestation, is a major public health concern. It affects about 10% of all newborns globally and is the main cause of infant death and morbidity. Prematurity increases the likelihood of respiratory distress syndrome, cerebral palsy, and developmental abnormalities. Furthermore, premature newborns are at risk of acquiring chronic noncommunicable diseases later in life due to interference with organ system development during the in-utero and perinatal period. Because of the greater risk of long-term repercussions, preterm birth should be considered a chronic disorder, and gestational age and other birth histories should be included in all medical records for patients of all ages, especially when assessing the risk of multiple chronic diseases. Conventional methods for assessing preterm infant development, as well as reliable and precise growth monitoring, can lead to the early detection of growth decline and the adjustment of feeding regimens as needed. Because of its unique composition and useful components, human milk is a powerful tool for mitigating the negative outcomes associated with prematurity. It contains a variety of growth factors that promote the development of organs and systems, counteracting the negative effects of the abrupt interruption of intrauterine development and promoting better outcomes in all altered functions. Despite its multiple benefits, human milk cannot totally restore the lasting damage caused by premature birth. Premature infants cannot be completely overcome by nutrition alone, and yet adequate nutritional intake and human milk feeding are critical to their health and development.

Impact of early-onset preeclampsia on feeding tolerance and growth of very low birth weight infants during hospitalization

OBJECTIVE

The provision of adequate enteral nutrition to preterm infants is a great challenge, and preeclampsia (PE) may have a detrimental effect on the safety of nutrition supply. This study aims to investigate the influence of early-onset PE on preterm infants' enteral feeding tolerance and growth during hospitalization.

METHODS

This is a prospective study with 55 preterm infants <34 weeks born to PE mothers matched by gestational age with 55 preterm infants born to normotensive mothers from 2013 to 2016. We evaluated maternal, gestational, and neonatal clinical data. The outcomes were feeding intolerance and growth during hospitalization. Comparison between groups was performed by Student's t-test or Mann-Whitney U test, chi-square test, or Fisher's exact test. Multiple logistic regression was used to investigate whether PE was an independent risk factor for feeding intolerance.

RESULTS

The mean gestational age was 30 weeks. Preterm infants of mothers with PE had lower birth weight and were smaller at discharge. Feeding intolerance was frequent, but necrotizing enterocolitis was rare in this sample (PE=4% vs. control=2%) with no difference between groups. Preterm infants of mothers with PE had worse growth outcomes; however, PE was not an independent risk factor for feeding intolerance. The increase in gestational age was a protective factor, and being born small for gestational age (SGA) increased the risk of feeding intolerance by six times.

CONCLUSIONS

Preterm infants of mothers with early-onset PE were more likely to be born SGA and had a worse growth trajectory during hospitalization. In adjusted analyses, however, low gestational age and SGA were independent predictors of feeding intolerance.

Cerebral Effects of Neonatal Dysglycemia

This article summarizes the available evidence reporting the relationship between perinatal dysglycemia and long-term neurodevelopment. We review the physiology of perinatal glucose metabolism and discuss the controversies surrounding definitions of perinatal dysglycemia. We briefly review the epidemiology of hypoglycemia and hyperglycemia in fetal, preterm, and term infants. We discuss potential pathophysiologic mechanisms contributing to dysglycemia and its effect on neurodevelopment. We highlight current strategies to prevent and treat dysglycemia in the context of neurodevelopmental outcomes. Finally, we discuss areas of future research and the potential role of continuous glucose monitoring.

Understanding the Preterm Human Heart: What do We Know So Far?

Globally, preterm birth affects more than one in every 10 live births. Although the short‐term cardiopulmonary complications of prematurity are well known, long‐term health effects are only now becoming apparent. Indeed, preterm birth has been associated with elevated cardiovascular morbidity and mortality in adulthood. Experimental animal models and observational human studies point toward changes in heart morphology and function from birth to adulthood in people born preterm that may contribute to known long‐term risks. Moreover, recent data support the notion of a heterogeneous cardiac phenotype of prematurity, which is likely driven by various maternal, early, and late life factors. This review aims to describe the early fetal‐to‐neonatal transition in preterm birth, the different structural and functional changes of the preterm human heart across developmental stages, as well as potential factors contributing to the cardiac phenotype of prematurity.

Delayed introduction of progressive enteral feeds to prevent necrotising enterocolitis in very low birth weight infants

BACKGROUND

Enteral feeding for very preterm or very low birth weight (VLBW) infants is often delayed for several days after birth due to concern that early introduction of feeding may not be tolerated and may increase the risk of necrotising enterocolitis. Concerns exist, however, that delaying enteral feeding may diminish the functional adaptation of the gastrointestinal tract and prolong the need for parenteral nutrition with its attendant infectious and metabolic risks.

OBJECTIVES

To determine the effects of delayed introduction of progressive enteral feeds on the risk of necrotising enterocolitis, mortality and other morbidities in very preterm or VLBW infants.

SEARCH METHODS

Search strategies were developed by an information specialist in consultation with the review authors. The following databases were searched in October 2021 without date or language restrictions: CENTRAL (2021, Issue 10), MEDLINE via OVID (1946 to October 2021), Embase via OVID (1974 to October 2021), Maternity and Infant Care via OVID (1971 to October 2021), CINAHL (1982 to October 2021). We also searched for eligible trials in clinical trials databases, conference proceedings, previous reviews, and reference lists of retrieved articles.

SELECTION CRITERIA

Randomised controlled trials that assessed the effects of delayed (four or more days after birth) versus earlier introduction of progressive enteral feeds on necrotising enterocolitis, mortality and other morbidities in very preterm or VLBW infants.

DATA COLLECTION AND ANALYSIS

Two review authors separately evaluated trial risk of bias, extracted data, and synthesised effect estimates using risk ratio (RR), risk difference (RD), and mean difference. We used the GRADE approach to assess the certainty of evidence for effects on necrotising enterocolitis, mortality,  feed intolerance, and invasive infection.

MAIN RESULTS

We included 14 trials in which a total of 1551 infants participated. Potential sources of bias were lack of clarity on methods to generate random sequences and conceal allocation in half of the trials, and lack of masking of caregivers or investigators in all of the trials. Trials typically defined delayed introduction of progressive enteral feeds as later than four to seven days after birth and early introduction as four days or fewer after birth. Infants in six trials (accounting for about half of all of the participants) had intrauterine growth restriction or circulatory redistribution demonstrated by absent or reversed end-diastolic flow velocities in the fetal aorta or umbilical artery.  Meta-analyses showed that delayed introduction of progressive enteral feeds may not reduce the risk of necrotising enterocolitis (RR 0.81, 95% confidence interval (CI) 0.58 to 1.14; RD -0.02, 95% CI -0.04 to 0.01; 13 trials, 1507 infants; low-certainty evidence due risk of bias and imprecision) nor all-cause mortality before hospital discharge (RR 0.97, 95% CI 0.70 to 1.36; RD -0.00, 95% CI -0.03 to 0.03; 12 trials, 1399 infants; low-certainty evidence due risk of bias and imprecision). Delayed introduction of progressive enteral feeds may slightly reduce the risk of feed intolerance (RR 0.81, 95% CI 0.68 to 0.97; RD -0.09, 95% CI -0.17 to -0.02; number needed to treat for an additional beneficial outcome = 11, 95% CI 6 to 50; 6 trials, 581 infants; low-certainty evidence due to risk of bias and imprecision) and probably increases the risk of invasive infection (RR 1.44, 95% CI 1.15 to 1.80; RD 0.10, 95% CI 0.04 to 0.15; number needed to treat for a harmful outcome = 10, 95% CI 7 to 25; 7 trials, 872 infants; moderate-certainty evidence due to risk of bias).  AUTHORS' CONCLUSIONS: Delaying the introduction of progressive enteral feeds beyond four days after birth (compared with earlier introduction) may not reduce the risk of necrotising enterocolitis or death in very preterm or VLBW infants. Delayed introduction may slightly reduce feed intolerance, and probably increases the risk of invasive infection.

A systematic review of the factors influencing microbial colonization of the preterm infant gut

Prematurity coupled with the necessary clinical management of preterm (PT) infants introduces multiple factors that can interfere with microbial colonization. This study aimed to review the perinatal, physiological, pharmacological, dietary, and environmental factors associated with gut microbiota of PT infants. A total of 587 articles were retrieved from a search of multiple databases. Sixty studies were included in the review after removing duplicates and articles that did not meet the inclusion criteria. Review of this literature revealed that evidence converged on the effect of postnatal age, mode of delivery, use of antibiotics, and consumption of human milk in the composition of gut microbiota of PT infants. Less evidence was found for associations with race, sex, use of different fortifiers, macronutrients, and other medications. Future studies with rich metadata are needed to further explore the impact of the PT exposome on the development of the microbiota in this high-risk population.

Feeding practices and the prevalence of cow's milk protein allergy in Irish preterm infants

BACKGROUND

The prevalence of cow's-milk protein allergy (CMPA) is between 2% and 3% and symptoms vary depending on underlying immune mechanism at play. Breast milk is the optimal nutrition for premature infants and breast milk fortifiers (BMF) are commonly used to optimise growth and nutrition. BMF are typically derived from cow's milk and, as such, preterm infants are exposed to cow's milk in the first weeks of life. Previously, preterm infants were suspected to have a higher risk of allergen development because of early antigen exposure and increased gut permeability. The primary aim of the present study was to evaluate the prevalence of CMPA among very preterm (<32 weeks) and/or very low birth weight (VLBW) infants. The secondary aim was to describe feeding practices, specifically the breastfeeding rates and specialist, non-standard formula use in this cohort over the first 6 months of life.

METHODS

This was a retrospective study performed in a large tertiary maternity hospital (8500 deliveries/year and 110 very preterm infants/year) in Dublin, Ireland over a 3-year period, 2017-2020. Infants born very preterm and/or VLBW who were followed in the outpatient clinic until 6 months corrected gestational age (CGA) were included. Hospital ethical approval was obtained.

RESULTS

One hundred and forty-four infants were included with a median birth weight of 1338 g. No infant had a diagnosis of CMPA when leaving the neonatal intensive care unit (NICU) but, by 6 months CGA, this increased to 1.4% (n = 2). Upon discharge from the NICU, 88 infants (61%) were receiving at least some breast milk, decreasing to 13 (9.1%) at 6 months CGA. Those who were receiving exclusive breast milk at discharge were significantly more likely to still be receiving any breast milk at three (p ≤ 0.001) and 6 months ( p ≤ 0.001) CGA compared to those combined feeding or exclusively formula feeding. At 6 months CGA, 18.9% (n = 27) were attending a dietician and 31.5% (n = 45) were using specialist, non-standard infant formula.

CONCLUSIONS

The prevalence of CMPA in this cohort was 1.4%, which is similar to the reported prevalence of CMPA in the general paediatric population. Infants who were discharged from NICU exclusively breastfeeding were more likely to be receiving any breast milk at outpatient follow-up. This highlights the importance of on going dietetic and lactation support in the outpatient setting for this vulnerable cohort.

Nutritional Management and Recommendation for Preterm Infants: A Narrative Review

Background: Preterm birth is defined as birth before 37 completed weeks of pregnancy. It is the most important predictor of adverse health and development infant outcomes that extend into the early childhood and beyond. It is also the leading cause of childhood mortality under 5 years of age worldwide and responsible for approximately one million neonatal deaths. It is also a significant contributor to childhood morbidities, with many survivors are facing an increased risk of lifelong disability and poor quality of life. Purpose: In this article, we aimed to describe features of preterm infants, what makes them different from term infants, and what to consider in nutritional management of preterm infants through a traditional narrative literature review. Discussion: Preterm infants are predisposed to more health complications than term infants with higher morbidity and mortality. This morbidity and mortality can be reduced through timely interventions for the mother and the preterm infant. Maternal interventions, such as health education and administration of micronutrient supplementation, are given before or during pregnancy and at delivery, whereas appropriate care for the preterm infants should be initiated immediately after birth, which include early breastfeeding and optimalization of weight gain. Conclusion: Essential care of the preterm infants and early aggressive nutrition should be provided to support rapid growth that is associated with improved neurodevelopmental outcomes. The goal is not only about survival but making sure that these preterm infants grow and develop without any residual morbidity.

Nutritional Intake, White Matter Integrity, and Neurodevelopment in Extremely Preterm Born Infants

Background: Determining optimal nutritional regimens in extremely preterm infants remains challenging. This study aimed to evaluate the effect of a new nutritional regimen and individual macronutrient intake on white matter integrity and neurodevelopmental outcome. Methods: Two retrospective cohorts of extremely preterm infants (gestational age < 28 weeks) were included. Cohort B (n = 79) received a new nutritional regimen, with more rapidly increased, higher protein intake compared to cohort A (n = 99). Individual protein, lipid, and caloric intakes were calculated for the first 28 postnatal days. Diffusion tensor imaging was performed at term-equivalent age, and cognitive and motor development were evaluated at 2 years corrected age (CA) (Bayley-III-NL) and 5.9 years chronological age (WPPSI-III-NL, MABC-2-NL). Results: Compared to cohort A, infants in cohort B had significantly higher protein intake (3.4 g/kg/day vs. 2.7 g/kg/day) and higher fractional anisotropy (FA) in several white matter tracts but lower motor scores at 2 years CA (mean (SD) 103 (12) vs. 109 (12)). Higher protein intake was associated with higher FA and lower motor scores at 2 years CA (B = −6.7, p = 0.001). However, motor scores at 2 years CA were still within the normal range and differences were not sustained at 5.9 years. There were no significant associations with lipid or caloric intake. Conclusion: In extremely preterm born infants, postnatal protein intake seems important for white matter development but does not necessarily improve long-term cognitive and motor development.

Adiponectin and the regulation of gastric content volume in the newborn rat

BACKGROUND

Oral intake is dependent on the gastric ability to accommodate the food bolus. Comparatively, neonates have a smaller gastric capacity than adults and this may limit the volume of their milk intake. Yet, we previously reported that the newborn rat gastric milk volume is greatest after birth and, when normalized to body weight, decreases with postnatal age. Such age-dependent changes are not the result of intake differences, but greater gastric accommodation and reduced emptying rate.

AIM

Hypothesizing that breastmilk-derived adiponectin is the factor regulating gastric accommodation in neonates, we comparatively evaluated its effects on the rat fundic muscle tone at different postnatal ages.

METHODS

In freshly dispersed smooth muscle cells (SMC), we measured the adiponectin effect on the carbachol-induced length changes.

RESULTS

Adiponectin significantly reduced the carbachol-stimulated SMC shortening independently of age. In the presence of the inhibitor iberiotoxin, the adiponectin effect on SMC shortening was suppressed, suggesting that it is mediated via large-conductance Ca²⁺ sensitive K⁺ channel activation. Lastly, we comparatively measured the newborn rat gastric milk curd adiponectin content in one- and two-week-old rats and found a 50% lower value in the latter.

CONCLUSION

Adiponectin, a major component of breastmilk, downregulates fundic smooth muscle contraction potential, thus facilitating gastric volume accommodation. This rodent’s adaptive response maximizes breastmilk intake volume after birth.

Slow advancement of enteral feed volumes to prevent necrotising enterocolitis in very low birth weight infants

BACKGROUND

Early enteral feeding practices are potentially modifiable risk factors for necrotising enterocolitis (NEC) in very preterm or very low birth weight (VLBW) infants. Observational studies suggest that conservative feeding regimens, including slowly advancing enteral feed volumes, reduce the risk of NEC. However, it is unclear whether slow feed advancement may delay establishment of full enteral feeding, and if it could be associated with infectious morbidities secondary to prolonged exposure to parenteral nutrition.

OBJECTIVES

To determine the effects of slow rates of enteral feed advancement on the risk of NEC, mortality, and other morbidities in very preterm or VLBW infants.

SEARCH METHODS

We searched CENTRAL (2020, Issue 10), Ovid MEDLINE (1946 to October 2020), Embase via Ovid (1974 to October 2020), Maternity and Infant Care database (MIDIRS) (1971 to October 2020), CINAHL (1982 to October 2020), and clinical trials databases and reference lists of retrieved articles for eligible trials.

SELECTION CRITERIA

We included randomised or quasi-randomised controlled trials that assessed effects of slow (up to 24 mL/kg/d) versus faster rates of advancement of enteral feed volumes on the risk of NEC in very preterm or VLBW infants.

DATA COLLECTION AND ANALYSIS

Two review authors separately evaluated trial risk of bias, extracted data, and synthesised effect estimates using risk ratio (RR), risk difference (RD), and mean difference. We used the GRADE approach to assess the certainty of evidence. Outcomes of interest were NEC, all-cause mortality, feed intolerance, and invasive infection.

MAIN RESULTS

We included 14 trials involving a total of 4033 infants (2804 infants participated in one large trial). None of the trials masked parents, caregivers, or investigators. Risk of bias was otherwise low. Most infants were stable very preterm or VLBW infants of birth weight appropriate for gestation. About one-third of all infants were extremely preterm or extremely low birth weight (ELBW), and about one-fifth were small for gestational age, growth-restricted, or compromised as indicated by absent or reversed end-diastolic flow velocity in the foetal umbilical artery. Trials typically defined slow advancement as daily increments of 15 to 24 mL/kg, and faster advancement as daily increments of 30 to 40 mL/kg. Meta-analyses showed that slow advancement of enteral feed volumes probably has little or no effect on the risk of NEC (RR 1.06, 95% confidence interval (CI) 0.83 to 1.37; RD 0.00, 95% CI -0.01 to 0.02; 14 trials, 4026 infants; moderate-certainty evidence) or all-cause mortality prior to hospital discharge (RR 1.13, 95% CI 0.91 to 1.39; RD 0.01, 95% CI -0.01 to 0.02; 13 trials, 3860 infants; moderate-certainty evidence). Meta-analyses suggested that slow advancement may slightly increase feed intolerance (RR 1.18, 95% CI 0.95 to 1.46; RD 0.05, 95% CI -0.02 to 0.12; 9 trials, 719 infants; low-certainty evidence) and may slightly increase the risk of invasive infection (RR 1.14, 95% CI 0.99 to 1.31; RD 0.02, 95% CI -0.00 to 0.05; 11 trials, 3583 infants; low-certainty evidence).

AUTHORS' CONCLUSIONS

The available trial data indicate that advancing enteral feed volumes slowly (daily increments up to 24 mL/kg) compared with faster rates probably does not reduce the risk of NEC, death, or feed intolerance in very preterm or VLBW infants. Advancing the volume of enteral feeds at a slow rate may slightly increase the risk of invasive infection.

Long-Term Outcomes after Early Neonatal Hyperglycemia in VLBW Infants: A Systematic Review

INTRODUCTION

Long-term effects of early hyperglycemia in VLBW infants are poorly characterized. The objective of this study was to systematically review the effect of early hyperglycemia on growth, metabolic health, and neurodevelopment after neonatal intensive care unit discharge in VLBW infants.

METHODS

The systematic review was conducted in accordance with the PRISMA guidelines. A study protocol was registered in PROSPERO (CRD42019123335). Data sources included Ovid MEDLINE, Embase, Cochrane Library, CINAHL, and Scopus. Selected studies included infants with a blood glucose concentration >150 mg/dL (8.3 mmol/L) during the first 28 days of life, a gestational age (GA) <32 weeks, and/or a birth weight <1,500 g and longitudinal data on growth, metabolic health, or neurodevelopment outcomes. The GRADE system was used to assess quality of evidence.

RESULTS

Eight studies (n = 987 infants) reported long-term outcomes from 4-month corrected GA to 7 years old. Most studies compared long-term outcomes of preterm infants with and without hyperglycemia. Two studies addressed outcomes related to interventions following early hyperglycemia. Some studies found differences in growth, metabolic health, and neurodevelopment outcomes between VLBW preterm infants with hyperglycemia and without hyperglycemia, while other studies found no differences between groups. The overall graded quality of evidence was low.

CONCLUSIONS

Well-designed randomized controlled and prospective studies are necessary to determine the effect of early hyperglycemia and its treatment on later metabolic and neurodevelopmental outcomes in VLBW infants. Authors propose a potential study design for standardizing the assessment of long-term metabolic and neurodevelopmental outcomes following early hyperglycemia in preterm infants.

Effects of Total Enteral Nutrition on Early Growth, Immunity, and Neuronal Development of Preterm Infants

The feeding of colostrum and mother's transitional milk improves immune protection and neurodevelopmental outcomes. It also helps with gut maturation and decreases the risks of infection. The supply of nutrients from human milk (HM) is not adequate for preterm infants, even though preterm mother's milk contains higher concentrations of protein, sodium, zinc, and calcium than mature HM. The human milk fortifiers, particularly those with protein, calcium, and phosphate, should be used to supplement HM to meet the necessities of preterm infants. The management of fluid and electrolytes is a challenging aspect of neonatal care of preterm infants. Trace minerals such as iron, zinc, copper, iodine, manganese, molybdenum, selenium, chromium, and fluoride are considered essential for preterm infants. Vitamins such as A, D, E, and K play an important role in the prevention of morbidities, such as bronchopulmonary dysplasia, retinopathy of prematurity, and intraventricular hemorrhage. Therefore, supplementation of HM with required nutrients is recommended for all preterm infants.

Association between Neonatal Intakes and Hyperglycemia, and Left Heart and Aortic Dimensions at 6.5 Years of Age in Children Born Extremely Preterm

Survivors of extremely preterm birth (gestational age < 27 weeks) have been reported to exhibit an altered cardiovascular phenotype in childhood. The mechanisms are unknown. We investigated associations between postnatal nutritional intakes and hyperglycemia, and left heart and aortic dimensions in children born extremely preterm. Postnatal nutritional data and echocardiographic dimensions at 6.5 years of age were extracted from a sub-cohort of the Extremely Preterm Infants in Sweden Study (EXPRESS; children born extremely preterm between 2004-2007, n = 171, mean (SD) birth weight = 784 (165) grams). Associations between macronutrient intakes or number of days with hyperglycemia (blood glucose > 8 mmol/L) in the neonatal period (exposure) and left heart and aortic dimensions at follow-up (outcome) were investigated. Neonatal protein intake was not associated with the outcomes, whereas higher lipid intake was significantly associated with larger aortic root diameter (B = 0.040, p = 0.009). Higher neonatal carbohydrate intake was associated with smaller aorta annulus diameter (B = -0.016, p = 0.008). Longer exposure to neonatal hyperglycemia was associated with increased thickness of the left ventricular posterior wall (B = 0.004, p = 0.008) and interventricular septum (B = 0.004, p = 0.010). The findings in this study indicate that postnatal nutrition and hyperglycemia may play a role in some but not all long-lasting developmental adaptations of the cardiovascular system in children born extremely preterm.

Overview of Important Micronutrients Supplementation in Preterm Infants after Discharge: A Call for Consensus

Preterm infants have a lower level of nutrient body stores and immature body systems, resulting in a higher risk of malnutrition. Imbalanced complementary feeding could lead to further risk of nutritional deficits and excesses. However, evidence on their nutritional requirements following hospital discharge is limited. When planning complementary feeding, appropriate micronutrient intake should be considered for their critical role in supporting various body functions. This narrative review summarizes the need for iron, zinc, vitamin D, calcium, phosphate and long-chain polyunsaturated fatty acids (LCPUFAs) supplementation in preterm infants during complementary feeding. Regarding iron and vitamin D, the scientific community is reaching an agreement on supplementation in some categories of prematures. On the contrary, there is still not enough evidence to detail possible recommendations for LCPUFAs, zinc, calcium and phosphorus supplementation. However, these micronutrients are paramount for preterms' health: LCPUFAs can promote retinal and brain development while calcium and phosphorus supplementation is essential to prevent preterms' metabolic bone disease (MBD). Waiting for a consensus on these micronutrients, it is clear how the knowledge of the heterogeneity of the prematures population can help adjust the nutritional planning regarding the growth rate, comorbidities and comprehensive clinical history of the preterm infant.

Clinical and Nutritional Determinants of Extrauterine Growth Restriction Among Very Low Birth Weight Infants

Purpose

To identify the clinical and nutritional factors associated with extrauterine growth restriction (EUGR) among very low birth weight infants (VLBW) in a tertiary hospital in Jordan.

Patients and Methods

We conducted a retrospective analysis of all VLBW infants admitted at King Abdullah University Hospital between July 2015 and June 2020. Clinical factors, nutritional intake, and growth parameters were collected and analyzed. A multilogistic regression model was applied to identify factors associated with EUGR.

Results

Of the 247 VLBW infants included in analysis, 112 (45%) were males, 30 (12%) were below 1000 g, and 72 (29%) were small for gestational age (SGA). EUGR was diagnosed in 198 (80%) at discharge. The rates of EUGR among SGA and non-SGA infants were 97% and 73%, respectively. The EUGR infants had a higher gestational age (30.7 vs 29.8 weeks, p=0.04), a lower birth weight (1209 vs 1300 g, p=0.005), a longer ventilatory support (5.7 vs 2.2 days, p=0.03), a higher incidence of sepsis (23% vs 10%, p=0.05), and a longer hospitalization (46 vs 38 days, p=0.03). With multilogistic regression model, the factors associated with EUGR include small-for-gestational age (AOR 9, 95% C.I. 2, 50), >3-day delay in feeding initiation (AOR 3.8, 95% C.I. 1.2,10), >14-day delay in achieving full feeds (AOR 3.3, 95% C.I. 1.2, 8), <3 g/kg of protein intake on the 8th day (AOR 2.1, 95% C.I. 1.1, 4.1), <100 kcal/kg of total caloric intake on the 15th day (AOR 3.8, 95% C.I. 1.6, 8.9), and occurrence of sepsis (AOR 3, 95% C.I. 1.1, 9).

Conclusion

The rate of EUGR in our unit is high. In addition to being SGA at birth, sepsis and suboptimal protein and caloric intake in the first two weeks of life were significantly associated with this complication. A more aggressive enteral and parenteral nutritional approach is needed to minimize postnatal growth delay.

Implementation of the Reimbursement Cost of Human-Milk-Based Neonatal Therapy in Polish Health Care Service : Practical and Ethical Background

BACKGROUND

A human-milk-based diet is the best option for nutritional therapy for preterm and/or sick newborns.

RESEARCH AIM

The study aims were to restructure the reimbursement rates to hospitals in Poland for infants' tube feedings to favor the use of donor human milk over formula for newborns who required supplementation of expressed mother's milk and evaluate the results of the financing change during the first year of implementation (2018).

METHODS

Financial data from hospitals were collected (2015-2016) by the Human Milk Bank Foundation using a data sheet designed by the Agency for Health Technology Assessment and Tariff System. We used data to restructure the reimbursement rates to hospitals for infants' tube feedings and implemented the changes in late 2017. The National Health Fund was requested to share reported data in 2018 concerning tube feeding services.

RESULTS

More than half (61%) of NICUs introduced human milk tube feeding for newborns. It was provided to participants (N = 5,530), most frequently to seriously ill preterm infants (66.6%). Of these infants, 2,323 were fed donor human milk. Only 1,925 newborns received formula tube feeding. However, there were large differences in frequency of services reported among various parts of the country.

CONCLUSIONS

Based on our knowledge, Poland is the only European country where the reimbursement cost for human-milk-based nutritional therapy has been implemented in a manner intended to increase the quality of health care services for preterm newborns. Equal reimbursement for expressed mother's milk and donor milk did not appear to cause overuse of donor milk based on our analysis of the 2018 data.

Plasma ammonia concentrations in extremely low birthweight infants in the first week after birth: secondary analysis from the ProVIDe randomized clinical trial

BACKGROUND

Little is known about normative ammonia concentrations in extremely low birthweight (ELBW) babies and whether these vary with birth characteristics. We aimed to determine ammonia concentrations in ELBW babies in the first week after birth and relationships with neonatal characteristics and protein intake.

METHODS

Arterial blood samples for the measurement of plasma ammonia concentration were collected within 7 days of birth from ProVIDe trial participants in six New Zealand neonatal intensive care units.

RESULTS

Three hundred and twenty-two babies were included. Median (range) gestational age was 25.7 (22.7-31.6) weeks. Median (interquartile range (IQR)) ammonia concentration was 102 (80-131) µg/dL. There were no statistically significant associations between ammonia concentrations and birthweight or sex. Ammonia concentrations were weakly correlated with mean total (Spearman's rs = 0.11, P = 0.047) and intravenous (rs = 0.13, P = 0.02) protein intake from birth, gestational age at birth (rs = -0.13, P = 0.02) and postnatal age (rs = -0.13, P = 0.02).

CONCLUSIONS

Plasma ammonia concentrations in ELBW babies are similar to those of larger and more mature babies and only weakly correlated with protein intake. Currently, recommended thresholds for investigation of hyperammonaemia are appropriate for ELBW babies. Protein intake should not be limited by concerns about potential hyperammonaemia.

Renal function in the third year among very low birth weight infants fed by supplemental proteins

Very Low Birth Weight (VLBW) infants have higher nutritional needs than term infants. Energy and protein are two important factors influencing their growth. Breastfeeding is not enough to meet VLBW infants' needs, for this reason, complementary protein is required by them. Hence, the present study aimed at investigation of renal function among VLBW infants receiving complementary proteins. The study was conducted on two groups of intervention and control (n= 18 in each group) (Case study: VLBW infants born in Akbarabadi hospital of Tehran in 2014 2015). The intervention group includes 3-year-old children who weighting less than 1200 grams at birth and have received protein supplementation at the course of NICU hospitalization, protein was added to maternal milk when the amount of milk reaches to 100 cc/kg/day, at this time parenteral nutrition was discontinued and the volume of feeding was increased 20cc/kg/day until reached to 150-180cc/kg/day. We also added the fortifier to breast milk at this time. The fortification and the protein supplementation were stopped when the weight of the baby reached to 1500 grams. The control group was fed similar to the intervention group but had received no complementary protein . The renal function was evaluated by measuring such criteria as BUN, Cr, ALB and U/A. After data collection, a statistical analysis was performed using SPSS software Ver. 22. Following to BUN evaluation, a significant correlation was seen between BUN and received protein (p-value=0.010). However, there was no significant correlation between Cr and received protein as well as mean values of the two groups (p-value=0.0766). Similarly, an insignificant correlation was found between the two groups following to investigation of ALB (p-value=0/257), while the mean values of the two groups were similar. The both groups were also equal in U/A. The complementary protein increased the BUN with no effect on Cr, ALB and U/A, providing no impact on renal function. Therefore, complementary protein intake made no conflict in renal function.

The microbial biogeography of the gastrointestinal tract of preterm and term lambs

Nutritional supplementation is a common clinical intervention to support the growth of preterm infants. There is little information on how nutritional supplementation interacts with the developing microbiome of the small intestine, the major site for nutrient metabolism and absorption. We investigated the effect of preterm birth and nutritional supplementation on the mucosal and luminal microbiota along the gastrointestinal tract (GIT) of preterm lambs. Preterm lambs (n = 24) were enterally supplemented with branched-chain amino acids (BCAAs), carbohydrate (maltodextrin), or water for two weeks from birth. Term lambs (n = 7) received water. Mucosal scrapings and luminal samples were collected from the duodenum, jejunum, ileum (small intestine) and colon at six weeks post-term age and analysed by 16S rRNA amplicon sequencing. Anatomical site explained 54% (q = 0.0004) of the variance and differences between the term and preterm groups explained 5.7% (q = 0.024) of the variance in microbial beta-diversities. The colon was enriched with Tenericutes and Verrucomicrobia compared to the small intestine, while Actinobacteria, and superphylum Patescibacteria were present in higher abundance in the small intestine compared to the colon. Our findings highlight that early-life short-term nutritional supplementation in preterm lambs does not alter the microbial community residing in the small intestine and colon.

A Guide to Feeding Term and Preterm Newborns

The management of feeding term and preterm newborns encompasses knowing the physiologic mechanics of nutritive feeding and requirements for good somatic and neurodevelopmental growth. Feeding in newborns can be fraught with challenges that each individual infant-family unit presents. Management is multifactorial and requires fluidity as the infant progresses. Pediatricians are tasked with one of the most important responsibilities in the newborn period-partnering with families to ensure optimal feeding regimen and infant growth. This article's aim is to outline general recommendations on evidence-based feeding practices in term and preterm infants with a goal to help guide pediatricians create an optimal individualized feeding regimen and address some known hurdles. [Pediatr Ann. 2020;49(2):e71-e76.].

Renal function in the third year among very low birth weight infants fed by supplemental proteins

Very Low Birth Weight (VLBW) infants have higher nutritional needs than term infants. Energy and protein are two important factors influencing their growth. Breastfeeding is not enough to meet VLBW infants’ needs, for this reason, complementary protein is required by them. Hence, the present study aimed at investigation of renal function among VLBW infants receiving complementary proteins. The study was conducted on two groups of intervention and control (n= 18 in each group) (Case study: VLBW infants born in Akbarabadi hospital of Tehran in 2014 2015). The intervention group includes 3-year-old children who weighting less than 1200 grams at birth and have received protein supplementation at the course of NICU hospitalization, protein was added to maternal milk when the amount of milk reaches to 100 cc/kg/day, at this time parenteral nutrition was discontinued and the volume of feeding was increased 20cc/kg/day until reached to 150-180cc/kg/day. We also added the fortifier to breast milk at this time. The fortification and the protein supplementation were stopped when the weight of the baby reached to 1500 grams. The control group was fed similar to the intervention group but had received no complementary protein . The renal function was evaluated by measuring such criteria as BUN, Cr, ALB and U/A. After data collection, a statistical analysis was performed using SPSS software Ver. 22. Following to BUN evaluation, a significant correlation was seen between BUN and received protein (p-value=0.010). However, there was no significant correlation between Cr and received protein as well as mean values of the two groups (p-value=0.0766). Similarly, an insignificant correlation was found between the two groups following to investigation of ALB (p-value=0/257), while the mean values of the two groups were similar. The both groups were also equal in U/A. The complementary protein increased the BUN with no effect on Cr, ALB and U/A, providing no impact on renal function. Therefore, complementary protein intake made no conflict in renal function.

Nutrition in late preterm infants

Late preterm infants comprise the majority of preterm infants, yet there are few data to support best nutritional practice for these infants. Breastmilk is considered the best choice of enteral feeding for late preterm infants. However, supplementation of breastmilk may be indicated to promote optimal growth. Preterm formulas can be used for supplementation of breastmilk or as a breastmilk substitute but there is little evidence for their use in the late preterm infant. Feeding difficulties are common and some infants require intravenous nutritional support soon after birth. Others require tube feeding until full sucking feeds are established. Future research should focus on whether nutritional support of late preterm babies pending exclusive breastfeeding influences growth, body composition and long-term outcomes of late preterm infants and, if so, how nutritional interventions can optimise these outcomes.

The Influence of Early Nutrition on Brain Growth and Neurodevelopment in Extremely Preterm Babies: A Narrative Review

Extremely preterm babies are at increased risk of less than optimal neurodevelopment compared with their term-born counterparts. Optimising nutrition is a promising avenue to mitigate the adverse neurodevelopmental consequences of preterm birth. In this narrative review, we summarize current knowledge on how nutrition, and in particular, protein intake, affects neurodevelopment in extremely preterm babies. Observational studies consistently report that higher intravenous and enteral protein intakes are associated with improved growth and possibly neurodevelopment, but differences in methodologies and combinations of intravenous and enteral nutrition strategies make it difficult to determine the effects of each intervention. Unfortunately, there are few randomized controlled trials of nutrition in this population conducted to determine neurodevelopmental outcomes. Substantial variation in reporting of trials, both of nutritional intakes and of outcomes, limits conclusions from meta-analyses. Future studies to determine the effects of nutritional intakes in extremely preterm babies need to be adequately powered to assess neurodevelopmental outcomes separately in boys and girls, and designed to address the many potential confounders which may have clouded research findings to date. The development of minimal reporting sets and core outcome sets for nutrition research will aid future meta-analyses.