The Impact of Neonatal Illness on Nutritional Requirements-One Size Does Not Fit All

Postnatal growth restriction impairs rat lung structure and function

The negative impact of nutritional deficits in the development of bronchopulmonary dysplasia is well recognized, yet mechanisms by which nutrition alters lung outcomes and nutritional strategies that optimize development and protect the lung remain elusive. Here, we use a rat model to assess the isolated effects of postnatal nutrition on lung structural development without concomitant lung injury. We hypothesize that postnatal growth restriction (PGR) impairs lung structure and function, critical mediators of lung development, and fatty acid profiles at postnatal day 21 in the rat. Rat pups were cross-fostered at birth to rat dams with litter sizes of 8 (control) or 16 (PGR). Lung structure and function, as well as serum and lung tissue fatty acids, and lung molecular mediators of development, were measured. Male and female PGR rat pups had thicker airspace walls, decreased lung compliance, and increased tissue damping. Male rats also had increased lung elastance, increased lung elastin protein abundance, and lysol oxidase expression, and increased elastic fiber deposition. Female rat lungs had increased conducting airway resistance and reduced levels of docosahexaenoic acid in lung tissue. We conclude that PGR impairs lung structure and function in both male and female rats, with sex-divergent changes in lung molecular mediators of development.

A nomogram for predicting neonatal acute respiratory distress syndrome in patients with neonatal pneumonia after 34 weeks of gestation

Objective

To establish a prediction nomogram for early prediction of neonatal acute respiratory distress syndrome (NARDS).

Methods

This is a retrospective cross-sectional study conducted between January 2021 and December 2023. Clinical characteristics and laboratory results of cases with neonatal pneumonia were compared in terms of presence of NARDS diagnosis based on the Montreux Definition. The NARDS group and non-NARDS group were then compared to establish a prediction nomogram for early prediction of NARDS. The predictive accuracy and compliance of the model were evaluated using subject operating characteristic curves, area under the ROC curve, and calibration curves, and the model performance was estimated by self-lifting weight sampling. The Hosmer-Lemeshow test was used to assess the goodness of fit of the model.

Findings

NARDS group consisted of 104, non-NARDS group consisted of 238 newborns in our study. Gestational age, triple concave sign, blood glucose measurement after birth (Glu), Apgar score at the 5th minute (Apgar5), neutrophil count (ANC) and platelet count (PLT) are independent predictors of NARDS in late preterm and term newborns who present with progressive respiratory distress and require varying degrees of respiratory support within the first 24 h of life to minimize work of breathing and restore organismal oxygenation. The area under the ROC curve was 0.829 (95% CI = 0.785-0.873), indicating the model's strong predictive power. In addition, decision curve analysis showed that the model had significantly better net benefits.

Conclusion

In this study, a predictive column-line plot was constructed based on six clinically accessible conventional variables. Early application of this model has a better predictive effect on the early diagnosis of NARDS, thus facilitating more timely and effective interventions.

Insulin-like growth factor-1 and insulin-like growth factor binding protein-3 as early predictors of growth, body composition, and neurodevelopment in preterm infants

OBJECTIVE

To investigate the relationship between insulin-like growth factor 1 (IGF-1), insulin-like growth factor binding protein 3 (IGFBP-3) and long-term growth, body composition, and neurodevelopment in preterm infants.

STUDY DESIGN

Prospective data were collected from ≤32 weeks gestational age infant cohort (N = 50). IGF-1 and IGFBP-3 concentrations were measured at 1 week (early) and 35 weeks (late) post-menstrual age (PMA). Growth, body composition, and neurodevelopment outcomes were measured at 4 and 12 months PMA. Relationships were measured by linear regression analysis.

RESULTS

Early IGFBP-3 concentration was positively associated with neurodevelopment at 12 months PMA. Early IGF-1 concentration was positively associated with weight at 4 months PMA, head circumference at 12 months PMA, and body mass index at 12 months PMA. Late IGFBP-3 concentration was positively associated with weight at 4 months PMA.

CONCLUSION

Further investigation of these associations may lead to novel biomarkers and/or treatments to optimize health outcomes in preterm infants.

Nutrition Supply and Growth Post Nutrition Support Team Activity in Neonatal Intensive Care Unit

Purpose

For neonates admitted to the neonatal intensive care unit (NICU), appropriate nutritional assessment and intervention are important for adequate growth. In this study, we aimed to determine whether there were changes in the nutritional supply and growth status of premature infants hospitalized in the NICU after the introduction of the Nutrition support team (NST).

Methods

This study retrospectively analyzed premature infants admitted to the NICU for over 14 days. The average daily calorie, protein, and fat supply at 1 and 2 weeks after birth were compared before and after NST, and growth was evaluated by changes in length, weight, and head circumference z-scores at birth and 28 days after birth.

Results

A total of 79 neonates were included in the present study, with 32 in the pre-NST group and 47 in the post-NST group. The average daily energy supply during the first (p=0.001) and second (p=0.029) weeks postnatal was significantly higher in the post-NST group than in the pre-NST group. Lipid supply for the first week was significantly higher in the post-NST group than in the pre-NST group (p=0.010). The change in the z-score for length was significantly higher in the post-NST group than in the pre-NST group (p=0.049).

Conclusion

Nutrient supply and length z-score change increased significantly at 28 days after birth in the post-NST group. These results suggest that calorie calculators and NST activity can promote adequate growth and development in neonates.

An exploratory study of clinical factors associated with IGF-1 and IGFBP-3 in preterm infants

BACKGROUND

Despite advances in parenteral nutrition, postnatal growth failure in very low birthweight (VLBW) preterm infants is common and associated with chronic health problems. Insulin-like growth factor 1 (IGF-1) is positively associated with improved infant growth, but factors which promote IGF-1 levels in this population have not been clearly identified. The objective of this study was to explore early factors that influence IGF-1 in VLBW preterm infants.

METHODS

VLBW infants were enrolled into a prospective, randomized controlled nutrition trial (N = 87). Outcome measures included IGF-1 and IGFBP-3 levels measured at 35 weeks PMA. Linear regression analyses tested the relationships between candidate clinical predictors and levels of IGF-1 and IGFBP-3.

RESULTS

Higher protein intake, longer duration of parenteral nutrition, and lower IGFBP-3 levels at 1 week of life were associated with lower IGF-1 levels at 35 weeks PMA. Neither early markers of insulin resistance nor degree of illness were associated with IGF-1 levels at 35 weeks PMA.

CONCLUSION

Optimization of early nutrient intake, and attention to route of delivery, may have a lasting influence on IGF-1/IGFBP-3, and in turn, long-term health outcomes.

IMPACT

In very low birthweight preterm infants, early protein intake, duration of parenteral nutrition, and insulin-like growth factor binding protein 3 (IGFBP-3) levels at 1 week of life are positively associated with insulin-like growth factor 1 (IGF-1) levels at 35 weeks postmenstrual age. Data from this study highlight the influence of early nutrition on components of the endocrine axis in preterm infants. Strategies aimed at early initiation of enteral nutrition, as well as optimizing composition of parenteral nutrition, may bolster hormones involved in promoting preterm infant growth.

Risk Factors for Infection in Neonates With Intestinal Failure

PURPOSE

Neonates with intestinal failure (IF) are at risk for infection due to central venous access, and intestinal surgery. Infection can cause systemic inflammation and sepsis, potentially affecting growth. The purpose of this study was to identify risk factors for, and the potential impact of infection to help with preventative strategies.

METHODS

A retrospective review of infants with IF, at a single centre from 2018 to 2022 was conducted. Clinical characteristics, intestinal pathology, nutritional intake, and growth were compared among infants with bloodstream infection (BSI), other infection (OI) (urinary, respiratory, or wound), or no infection (NI) within 2 months of diagnosis. Mann-Whitney and Kruskal-Wallis tests were used for comparisons with p-values <0.05 considered significant.

RESULTS

Eighty-six infants were included, with gastroschisis (41%) and necrotizing enterocolitis (26%) the most common diagnoses. Fifty-nine % of infants developed infection (22% BSI and 37% OI). Those with BSI or OI had a lower gestational age and birthweight, and were more likely to have a stoma. All infants with complex gastroschisis developed infection compared to 38% of infants with simple gastroschisis. Median daily weight gain was suboptimal across all groups and did not differ over 6 weeks following infection.

CONCLUSION

Most infants with IF develop infection shortly after diagnosis. Risk factors include prematurity, complex gastroschisis, and the presence of a stoma. Growth was suboptimal but did not differ among infants with or without infection.

TYPE OF STUDY

Retrospective Review.

LEVEL OF EVIDENCE

Level III Retrospective Comparative Study.

Targeting optimal protein delivery in parenteral and enteral nutrition for preterm infants: a review of randomized, controlled trials

Close attention to nutritional management is essential for optimizing growth and neurodevelopment of the preterm infant. Protein intake and the protein to energy ratio are the main determinants of growth and body composition. Yet large, multi-center, randomized controlled trials are lacking to guide protein delivery for the preterm infant. Until these studies are pursued, smaller trials must be used to inform clinical practice. This review summarizes the randomized controlled trials that have been performed to test the impact of higher vs. lower protein delivery to the preterm infant. We consider the trials that varied protein delivery rates during parenteral and enteral phases of nutrition. Considerable heterogeneity exists across study designs. Still, cumulative evidence from these trials provides a framework for current recommendations for protein intake in the preterm infant.

Association Between Hypoglycemia and the Occurrence of Early Onset Sepsis in Premature Infants

BACKGROUND

We examined the association between hypoglycemia and the occurrence of early onset sepsis (EOS) in premature infants admitted to the neonatal intensive care unit (NICU).

METHODS

We included infants discharged from 358 NICUs between 1997 and 2020 with gestational age <34 weeks, ≥1 culture collected in the first 3 days of life, and ≥1 serum glucose value recorded on the day of or day prior to culture collection. We used multivariable logistic regression and inverse probability weighting (IPW) and constructed models for three definitions of hypoglycemia: American Academy of Pediatrics (AAP), Pediatric Endocrine Society, and a definition based on neurodevelopmental studies. We performed subgroup analysis in EOS episodes caused by Gram-negative and Gram-positive organisms.

RESULTS

Of the 62,178 infants and 64,559 cultures that met study inclusion criteria, 739 (1%) cultures were positive. The median (25th, 75th percentile) glucose value was 75 mg/dL (50, 106) on the day of or day prior to a positive culture versus 70 mg/dL (50, 95) on the day of or day prior to a negative culture. We found that hypoglycemia was not associated with the occurrence of EOS for all organisms and Gram-positive organisms, whereas there was a small but significant association between the lower AAP glucose cutoff value and EOS due to Gram-negative organisms (logistic regression: risk difference [RD] 0.24% [95% CI, 0.01-0.47]; IPW: RD 0.22% [95% CI, 0.00-0.43]).

CONCLUSIONS

Hypoglycemia may be an early marker of EOS, particularly in episodes caused by Gram-negative organisms and when using a stricter definition of hypoglycemia.

Improving the Treatment of Neonatal Sepsis in Resource-Limited Settings: Gaps and Recommendations

Neonatal sepsis causes significant global morbidity and mortality, with the highest burden in resource-limited settings where 99% of neonatal deaths occur. There are multiple challenges to achieving successful treatment of neonates in this setting. Firstly, reliable and low-cost strategies for risk identification are urgently needed to facilitate treatment as early as possible. Improved laboratory capacity to allow identification of causative organisms would support antimicrobial stewardship. Antibiotic treatment is still hampered by availability, but also increasingly by antimicrobial resistance - making surveillance of organisms and judicious antibiotic use a priority. Finally, supportive care is key in the management of the neonate with sepsis and has been underrecognized as a priority in resource-limited settings. This includes fluid balance and nutritional support in the acute phase, and follow-up care in order to mitigate complications and optimise long-term outcomes. There is much more work to be done in identifying the holistic needs of neonates and their families to provide effective family-integrated interventions and complete the package of neonatal sepsis management in resource-limited settings.

Human milk fortification and use of infant formulas to support growth in the neonatal intensive care unit

Newborn infants require adequate nutrition to achieve full potential growth and development. Early life nutrition and health impacts long-term outcomes through adulthood. Human milk is the optimal source of nutrition during the first 6 months of life. However, infants admitted to the neonatal intensive care unit (NICU) often have comorbidities that create more or different nutrition demands than healthy newborns. There are different strategies to meet the nutrition needs of sick newborns, including use of parenteral nutrition, human milk fortifiers (HMFs), and infant formulas. Multinutrient HMFs are frequently used to achieve the higher nutrition demands of preterm infants. They are available in various presentations, such as human milk- or cow milk-derived, liquid or powder, and acidified or nonacidified, each of which has different risks and benefits associated with its use. Infant formulas are available to meet a demand when mother's own milk or donor breast milk is not available or sufficient, and there are also specialty formulas for infants with certain diseases that present unique nutrition needs. This review is focused on the use of HMFs to support the unique nutrition requirements of preterm infants for healthy growth, as well as the indications for the use of formulas among infants in the NICU.

Loss of growth differentiation factor 15 exacerbates lung injury in neonatal mice

Growth differentiation factor 15 (GDF15) is a divergent member of the transforming growth factor-β (TGF-β) superfamily, and its expression increases under various stress conditions, including inflammation, hyperoxia, and senescence. GDF15 expression is increased in neonatal murine bronchopulmonary dysplasia (BPD) models, and GDF15 loss exacerbates oxidative stress and decreases cellular viability in vitro. Our overall hypothesis is that the loss of GDF15 will exacerbate hyperoxic lung injury in the neonatal lung in vivo. We exposed neonatal Gdf15-/- mice and wild-type (WT) controls on a similar background to room air or hyperoxia (95% [Formula: see text]) for 5 days after birth. The mice were euthanized on postnatal day 21 (PND 21). Gdf15-/- mice had higher mortality and lower body weight than WT mice after exposure to hyperoxia. Hyperoxia exposure adversely impacted alveolarization and lung vascular development, with a greater impact in Gdf15-/- mice. Interestingly, Gdf15-/- mice showed lower macrophage count in the lungs compared with WT mice both under room air and after exposure to hyperoxia. Analysis of the lung transcriptome revealed marked divergence in gene expression and enriched biological pathways in WT and Gdf15-/- mice and differed markedly by biological sex. Notably, pathways related to macrophage activation and myeloid cell homeostasis were negatively enriched in Gdf15-/- mice. Loss of Gdf15 exacerbates mortality, lung injury, and the phenotype of the arrest of alveolarization in the developing lung with loss of female-sex advantage in Gdf15-/- mice.NEW & NOTEWORTHY We show for the first time that loss of Gdf15 exacerbates mortality, lung injury, and the phenotype of the arrest of alveolarization in the developing lung with loss of female-sex advantage in Gdf15-/- mice. We also highlight the distinct pulmonary transcriptomic response in the Gdf15-/- lung including pathways related to macrophage recruitment and activation.

Role of gut-brain axis in neurodevelopmental impairment of necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is a common gastrointestinal disease of preterm infants with high morbidity and mortality. In survivors of NEC, one of the leading causes of long-term morbidity is the development of severe neurocognitive injury. The exact pathogenesis of neurodevelopmental delay in NEC remains unknown, but microbiota is considered to have dramatic effects on the development and function of the host brain via the gut-brain axis. In this review, we discuss the characteristics of microbiota of NEC, the impaired neurological outcomes, and the role of the complex interplay between the intestinal microbiota and brain to influence neurodevelopment in NEC. The increasing knowledge of microbial-host interactions has the potential to generate novel therapies for manipulating brain development in the future.

Optimising growth in very preterm infants: reviewing the evidence

Infants born before 32 weeks' postmenstrual age are at a high risk of growth failure. International guidelines have long recommended that they match the growth of an equivalent fetus, despite the challenges posed by ex utero life and comorbidities of prematurity. Several groups have recently questioned the necessity or desirability of this target, shifting attention to aiming for growth which optimises important long-term outcomes. Specifically, recent research has identified the neurodevelopmental benefits of enhanced growth during the neonatal period, but work in term infant suggests that rapid growth may promote the metabolic syndrome in later life. In this context, defining a pattern of growth which optimises outcomes is complex, controversial and contested. Even if an optimal pattern of growth can be defined, determining the nutritional requirements to achieve such growth is not straightforward, and investigations into the nutritional needs of the very preterm infant continue. Furthermore, each infant has individual nutritional needs and may encounter a number of barriers to achieving good nutrition. This article offers a narrative review of recent evidence for the competing definitions of optimal growth in this cohort. It examines recent advances in the determination of macronutrient and micronutrient intake targets along with common barriers to achieving good nutrition and growth. Finally, key implications for clinical practice are set out and a recommendation for structured multidisciplinary management of nutrition and growth is illustrated.

Neonatal Selenium Deficiency Decreases Selenoproteins in the Lung and Impairs Pulmonary Alveolar Development

Decreased selenium (Se) levels during childhood and infancy are associated with worse respiratory health. Se is biologically active after incorporation into Se-containing antioxidant enzymes (AOE) and proteins. It is unknown how decreased maternal Se during pregnancy and lactation impacts neonatal pulmonary selenoproteins, growth, and lung development. Using a model of neonatal Se deficiency that limits Se intake to the dam during pregnancy and lactation, we evaluated which neonatal pulmonary selenoproteins are decreased in both the saccular (postnatal day 0, P0) and early alveolar (postnatal day 7, P7) stages of lung development. We found that Se deficient (SeD) pups weigh less and exhibit impaired alveolar development compared to Se sufficient (SeS) pups at P7. The activity levels of glutathione peroxidase (GPx) and thioredoxin reductase (Txnrd) were decreased at P0 and P7 in SeD lungs compared to SeS lungs. Protein content of GPx1, GPx3 and Txnrd1 were decreased in SeD lungs at P0 and P7, whereas Txnrd2 content was unaltered compared to SeS controls. The expression of NRF-2 dependent genes and several non-Se containing AOE were similar between SeS and SeD lungs. SeD lungs exhibited a decrease in selenoprotein N, an endoplasmic reticulum protein implicated in alveolar development, at both time points. We conclude that exposure to Se deficiency during pregnancy and lactation impairs weight gain and lung growth in offspring. Our data identify multiple selenoproteins in the neonatal lung that are vulnerable to decreased Se intake, which may impact oxidative stress and cell signaling under physiologic conditions as well as after oxidative stressors.

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.

Assessment of catabolic state in infants with the use of urinary titin N-fragment

BACKGROUND

Urinary titin N-fragment levels have been used to assess the catabolic state, and we used this biomarker to evaluate the catabolic state of infants.

METHODS

We retrospectively measured urinary titin N-fragment levels of urinary samples. The primary outcome was its changes according to postmenstrual age. The secondary outcomes included differences between gestational age, longitudinal change after birth, influence on growth, and relationship with blood tests.

RESULTS

This study included 219 patients with 414 measurements. Urinary titin N-fragment exponentially declined with postmenstrual age. These values were 12.5 (7.1-19.6), 8.1 (5.1-13.0), 12.8 (6.0-21.3), 26.4 (16.4-52.0), and 81.9 (63.3-106.4) pmol/mg creatinine in full, late, moderate, very, and extremely preterm infants, respectively (p < 0.01). After birth, urinary levels of titin N-fragment exponentially declined, and the maximum level within a week was associated with the time to return to birth weight in preterm infants (ρ = 0.39, p < 0.01). This was correlated with creatine kinase in full-term infants (ρ = 0.58, p < 0.01) and with blood urea nitrogen in preterm infants (ρ = 0.50, p < 0.01).

CONCLUSIONS

The catabolic state was increased during the early course of the postmenstrual age and early preterm infants.

IMPACT

Catabolic state in infants, especially in preterm infants, was expected to be increased, but no study has clearly verified this. In this retrospective study of 219 patients with 414 urinary titin measurements, the catabolic state was exponentially elevated during the early postmenstrual age. The use of the urinary titin N-fragment clarified catabolic state was prominently increased in very and extremely preterm infants.

Head circumference in infants undergoing Foker process for long-gap esophageal atresia repair: Call for attention

INTRODUCTION

We extended our pilot study in infants following long-gap esophageal atresia (LGEA) repair to report head circumference, an easily obtainable indirect measure of brain size. Data are presented in the context of previously reported body weight and T2-weighted MRI measures of intracranial and brain volumes.

METHODS

Clinical information and head circumference were obtained for term-born (n = 13) and premature (n = 13) infants following LGEA repair with Foker process, as well as healthy term-born controls (n = 20) <1-year corrected age who underwent non-sedated research MRI. General Linear Model univariate analysis with corrected age at scan as a covariate and Bonferroni adjusted p values assessed group differences.

RESULTS

We report no difference in head circumference between the three groups. Such findings paralleled trends in body weight and total intracranial volume but not in brain volume as previously reported for the same pilot cohort.

DISCUSSION

Results suggest uncompromised somatic and head growth after repair of LGEA. In contrast, a novel finding of discrepancy between head circumference (novel data) and brain size (previously published data) in the same cohort suggests that head circumference might not be the best indirect measure of brain size in selected group of patients.

Early Nutrition during Hospitalization in Relation to Bone Health in Preterm Infants at Term Age and Six Months Corrected Age

Aim: to evaluate the potential association of macronutrient intake in the first postnatal weeks on bone mineral content (BMC) and bone mineral density (BMD) in extremely and very preterm infants. Methods: fifty-eight extremely and very preterm infants were included. Daily macronutrient intake was calculated in g kg⁻¹ day⁻¹ from birth up to 36 weeks postmenstrual age. A dual-energy X-ray absorptiometry whole body scan was used to assess BMC and BMD in preterm infants at term corrected age (TCA) and six months corrected age (CA). Results: fat intake (g kg⁻¹ day⁻¹) in the first four postnatal weeks was positively associated with BMC and BMD at TCA. At six months CA, protein and fat intake (g kg⁻¹ day⁻¹) in the first weeks of life were both individual predictors for BMD. Fat intake (g kg⁻¹ day⁻¹) in the first four postnatal weeks was significantly associated with BMC at six months CA. Conclusion: the association of macronutrient intake in the first postnatal weeks on BMC or BMD, at TCA and six months CA, suggest that early nutritional intervention immediately after birth and during early infancy is important for bone health in the first months of life.

Higher Energy, Lipid, and Carbohydrate Provision to Very Low-Birth-Weight Infants Is Differentially Associated With Neurodevelopment at 18 Months, Despite Consistent Improvements in Weight Gain

BACKGROUND

The impact of suboptimal intakes on neurodevelopment of very low-birth-weight (VLBW, <1500 g) infants, particularly those born small for gestational age, <26 weeks, <1000 g, or with morbidities is not well defined. We investigated how macronutrient/energy intakes are associated with growth and neurodevelopment among VLBW infants, adjusted for the aforementioned vulnerabilities. Our hypothesis was that higher nutrient intakes would be positively associated with weight gain and neurodevelopment.

METHODS

Daily macronutrient/energy intakes and weekly weights from birth until 36⁺⁰ weeks were collected prospectively from VLBW infants (n = 302) enrolled in a previous trial (ISRCTN35317141). Neurodevelopment was assessed by the Bayley-III at 18 months' corrected gestational age. Relationships between quartiles of macronutrient/energy intakes, growth, and neurodevelopment were assessed.

RESULTS

Infants born <1000 g, <26 weeks, or with morbidities had lower nutrient intakes and slower growth than infants born ≥1000 g, ≥26 weeks, or with no morbidities, respectively (P < 0.05). Higher quartiles of energy, lipid, and carbohydrate intakes were positively associated with growth velocity (P = <0.0001-0.007); no association was observed for protein intake. Energy, protein-to-energy ratio and lipid intakes were associated with cognitive scores (P = 0.001-0.004); however, intakes within the second and third quartiles were generally associated with the highest cognitive scores. No nutrient intakes were associated with language or motor scores across the entire study period.

CONCLUSION

Smaller, more immature VLBW infants and those with morbidity have the greatest risk of poor nutrition and growth. Increasing macronutrient/energy intakes are generally associated with improved weight gain, but not necessarily improved neurodevelopment.

IL-6 Predicts Poor Early Post-Natal Growth in Very Low-Birth-Weight Infants in a Low-Middle Income Setting

BACKGROUND

Extra-uterine growth restriction (EUGR) is common in preterms and may be associated with elevated pro-inflammatory cytokines.

OBJECTIVE

Describe postnatal growth in a cohort of very low-birth-weight (VLBW) infants and determine the association of interleukin-6 (IL-6) and tumour necrosis factor alpha (TNF-α) in umbilical cord blood with growth at 40 weeks and 12 months postmenstrual age (PMA).

METHODS

Single-centre, prospective cohort study conducted from 1 June 2017 to 31 January 2019 with follow-up to 31 March 2020. Infants <1500 g at birth were enrolled, cord blood collected for IL-6 and TNF-α assays and postnatal care, including anthropometry, provided to 12 months PMA. Informed consent and ethics approval were obtained.

RESULTS

In total, 279 patients were enrolled; 84 (30.1%) died before 12 months and 91 (32.6%) lost to follow-up. Anthropometry was available for 151 infants at 40 weeks and 105 at 12 months. Z-Scores at 40 weeks for males and females combined were -2.5, -2.1 and -1.2 for weight, length and head circumference. EUGR occurred in 103/113 (91.2%), 98/107 (91.6%) and 70/109 (64.2%) participants for weight, length and head circumference. Elevated IL-6 was associated with restricted weight (56.0 vs. 14.5 pg/ml, p = 0.02) and length (60.4 vs. 7.3 pg/ml, p = 0.01) at 40 weeks. There was no difference in IL-6 at 12 months and no difference in TNF-α at 40 weeks or 12 months.

CONCLUSION

The study reports significant EUGR. Elevated IL-6 was associated with growth restriction at 40 weeks but not 12 months PMA.

Administration of an Intravenous Fat Emulsion Enriched with Medium-Chain Triglyceride/ω-3 Fatty Acids is Beneficial Towards Anti-Inflammatory Related Fatty Acid Profile in Preterm Neonates: A Randomized, Double-Blind Clinical Trial

Intravenous administration of pure soybean oil emulsions high in linoleic acid may lead to inflammation and lipid peroxidation in preterm neonates. We aimed to investigate the effects of a medium-chain triglyceride (MCT)/ω-3 polyunsaturated fatty acid (PUFA)-enriched intravenous fat emulsion (IVFE) on plasma fatty acid (FA) profile and serum interleukin-6 (IL-6) in preterm neonates. In this double-blind randomized study, 92 preterm neonates (gestational age < 32 weeks, birth weight < 1500 g) were assigned to receive either MCT/ω-3 PUFA-enriched IVFE (Intervention Group) or soybean oil-based IVFE (Control Group). Levels of FAs were measured at baseline (day 0) and day 15 of parenteral nutrition with gas-chromatography mass-spectrometry. Serum IL-6 was measured with sandwich ELISA in 59 neonates. Plasma FAs changed significantly over time; the MCT/ω-3 PUFA-IVFE group showed higher ω-3 PUFAs (p = 0.031), eicosapentaenoic acid (p = 0.000), and oleic acid (p = 0.003), and lower ω-6/ω-3 PUFAs ratio (p = 0.001) and ω-6 PUFAs (p = 0.023) compared to control group. Linoleic acid was higher in the soybean oil (SO)-based IVFE arm compared to the MCT/ω-3 PUFAs-IVFE arm (p = 0.006). Both fat emulsion types decreased IL-6 compared to baseline, but changes were insignificant between groups. Administration of MCT/ω-3 PUFA-enriched IVFE in preterm neonates is beneficial in changing the FA profile consistent with attenuated inflammatory response.

Successful use of an artificial placenta-based life support system to treat extremely preterm ovine fetuses compromised by intrauterine inflammation

BACKGROUND

Ex vivo uterine environment therapy is an experimental intensive care strategy for extremely preterm infants born between 21 and 24 weeks of gestation. Gas exchange is performed by membranous oxygenators connected by catheters to the umbilical vessels. The fetus is submerged in a bath of synthetic amniotic fluid. The lungs remain fluid filled, and pulmonary respiration does not occur. Intrauterine inflammation is strongly associated with extremely preterm birth and fetal injury. At present, there are no data that we are aware of to show that artificial placenta-based systems can be used to support extremely preterm fetuses compromised by exposure to intrauterine inflammation.

OBJECTIVE

To evaluate the ability of our ex vivo uterine environment therapy platform to support extremely preterm ovine fetuses (95-day gestational age; approximately equivalent to 24 weeks of human gestation) exposed to intrauterine inflammation for a period of 120 hours, the following primary endpoints were chosen: (1) maintenance of key physiological variables within normal ranges, (2) absence of infection and inflammation, (3) absence of brain injury, and (4) gross fetal growth and cardiovascular function matching that of age-matched in utero controls.

STUDY DESIGN

Ten ewes with singleton pregnancies were each given a single intraamniotic injection of 10-mg Escherichia coli lipopolysaccharides under ultrasound guidance 48 hours before undergoing surgical delivery for adaptation to ex vivo uterine environment therapy at 95-day gestation (term=150 days). Fetuses were adapted to ex vivo uterine environment therapy and maintained for 120 hours with constant monitoring of key vital parameters (ex vivo uterine environment group) before being killed at 100-day equivalent gestational age. Umbilical artery blood samples were regularly collected to assess blood gas data, differential counts, biochemical parameters, inflammatory markers, and microbial load to exclude infection. Ultrasound was conducted at 48 hours after intraamniotic lipopolysaccharides (before surgery) to confirm fetal viability and at the conclusion of the experiments (before euthanasia) to evaluate cardiac function. Brain injury was evaluated by gross anatomic and histopathologic investigations. Eight singleton pregnant control animals were similarly exposed to intraamniotic lipopolysaccharides at 93-day gestation and were killed at 100-day gestation to allow comparative postmortem analyses (control group). Biobanked samples from age-matched saline-treated animals served as an additional comparison group. Successful instillation of lipopolysaccharides into the amniotic fluid exposure was confirmed by amniotic fluid analysis at the time of administration and by analyzing cytokine levels in fetal plasma and amniotic fluid. Data were tested for mean differences using analysis of variance.

RESULTS

Six of 8 lipopolysaccharide control group (75%) and 8 of 10 ex vivo uterine environment group fetuses (80%) successfully completed their protocols. Six of 8 ex vivo uterine environment group fetuses required dexamethasone phosphate treatment to manage profound refractory hypotension. Weight and crown-rump length were reduced in ex vivo uterine environment group fetuses at euthanasia than those in lipopolysaccharide control group fetuses (P<.05). There were no biologically significant differences in cardiac ultrasound measurement, differential leukocyte counts (P>.05), plasma tumor necrosis factor α, monocyte chemoattractant protein-1 concentrations (P>.05), or liver function tests between groups. Daily blood cultures were negative for aerobic and anaerobic growth in all ex vivo uterine environment group animals. No cases of intraventricular hemorrhage were observed. White matter injury was identified in 3 of 6 lipopolysaccharide control group fetuses and 3 of 8 vivo uterine environment group fetuses.

CONCLUSION

We report the use of an artificial placenta-based system to support extremely preterm lambs compromised by exposure to intrauterine inflammation. Our data highlight key challenges (refractory hypotension, growth restriction, and white matter injury) to be overcome in the development and use of artificial placenta technology for extremely preterm infants. As such challenges seem largely absent from studies based on healthy pregnancies, additional experiments of this nature using clinically relevant model systems are essential for further development of this technology and its eventual clinical application.

Interactive and independent effects of early lipopolysaccharide and hyperoxia exposure on developing murine lungs

Bronchopulmonary dysplasia (BPD)-associated pulmonary hypertension (PH) is a chronic infantile lung disease that lacks curative therapies. Infants with BPD-associated PH are often exposed to hyperoxia and additional insults such as sepsis that contribute to disease pathogenesis. Animal models that simulate these scenarios are necessary to develop effective therapies; therefore, we investigated whether lipopolysaccharide (LPS) and hyperoxia exposure during saccular lung development cooperatively induce experimental BPD-PH in mice. C57BL/6J mice were exposed to normoxia or 70% O₂ (hyperoxia) during postnatal days (PNDs) 1-5 and intraperitoneally injected with varying LPS doses or a vehicle on PNDs 3-5. On PND 14, we performed morphometry, echocardiography, and gene and protein expression studies to determine the effects of hyperoxia and LPS on lung development, vascular remodeling and function, inflammation, oxidative stress, cell proliferation, and apoptosis. LPS and hyperoxia independently and cooperatively affected lung development, inflammation, and apoptosis. Growth rate and antioxidant enzyme expression were predominantly affected by LPS and hyperoxia, respectively, while cell proliferation and vascular remodeling and function were mainly affected by combined exposure to LPS and hyperoxia. Mice treated with lower LPS doses developed adaptive responses and hyperoxia exposure did not worsen their BPD phenotype, whereas those mice treated with higher LPS doses displayed the most severe BPD phenotype when exposed to hyperoxia and were the only group that developed PH. Collectively, our data suggest that an additional insult such as LPS may be necessary for models utilizing short-term exposure to moderate hyperoxia to recapitulate human BPD-PH.

Late Growth and Changes in Body Composition Influence Odds of Developing Retinopathy of Prematurity among Preterm Infants

Background: While postnatal growth in the first month of life is known to impact retinopathy of prematurity (ROP) risk, the impact of growth later in hospitalization, during critical times of retinal vascularization, remains unknown. The purpose of this study was to assess if postnatal growth and body composition during the second half of neonatal intensive care unit hospitalization were associated with severity of retinopathy of prematurity in very low birth weight preterm infants. Methods: Prospective observational pilot study of 83 infants born <32 weeks gestation and <1500 g, conducted at a Level IV neonatal intensive care unit. Body composition was measured during the second half of hospitalization. Infants were evaluated for retinopathy of prematurity. Logistic regression was performed. Results: Greater gains in fat mass, fat-free mass, and percent body fat from 32 to 37 weeks postmenstrual age and higher % body fat at term postmenstrual age were associated with decreased odds of ≥stage 2 retinopathy of prematurity (p < 0.05). Conclusions: Improved growth later in neonatal intensive care unit hospitalization and increased adiposity at term may reduce odds of severe retinopathy of prematurity.

ANALYSIS OF THE DIFFERENCES BETWEEN THE PRESCRIBED AND THE ADMINISTERED DIET TO PRETERM INFANTS USING AN ELECTRONIC TOO

ABSTRACT Objective: To create an electronic instrument in order to analyze the adequacy of the preterm infants’ nutritional therapy, checking the difference between the prescribed and the administered diet. Methods: A prospective and observational study on newborns with birthweight ≤1,500g and/or gestational age ≤32 weeks, without congenital malformations. The electronic instrument was developed based on Microsoft Excel 2010 spreadsheets and aimed at automatically calculating body weight gain, calories and macronutrients received daily by each patient from parenteral nutrition, intravenous hydration and enteral feedings. The weekly means of each nutrient were used to compare the prescribed and administered diets. Results: To evaluate the instrument, 60 newborns with a birth weight of 1,289±305 g and a gestational age of 30±2 weeks were included. Of them, 9.6% had restricted growth at birth and 55% at discharge. The median length of stay was 45±17 days. There were significant differences between prescribed and administered diet for all of the macronutrients and for total calories in the first three weeks. The lipid was the macronutrient with the greatest percentage error in the first week of life. Conclusions: The use of a computational routine was important to verify differences between the prescribed and the administered diet. This analysis is necessary to minimize calculation errors and to speed up health providers’ decisions about the nutritional approach, which can contribute to patients’ safety and to good nutritional practice. Very low birth weight infants are extremely vulnerable to nutritional deficiencies and any reduction in macronutrients they receive may be harmful to achieve satisfactory growth.

Applying Methods for Postnatal Growth Assessment in the Clinical Setting: Evaluation in a Longitudinal Cohort of Very Preterm Infants

AIM

To analyze different methods to assess postnatal growth in a cohort of very premature infants (VPI) in a clinical setting and identify potential early markers of growth failure.

METHODS

Study of growth determinants in VPI (≤32 weeks) during hospital stay. Nutritional intakes and clinical evolution were recorded. Growth velocity (GV: g/kg/day), extrauterine growth restriction (%) (EUGR: weight < 10th centile, z-score < -1.28) and postnatal growth failure (PGF: fall in z-score > 1.34) at 36 weeks postmenstrual age (PMA) were calculated. Associations between growth and clinical or nutritional variables were explored (linear and logistic regression).

RESULTS

Sample: 197 VPI. GV in IUGR patients was higher than in non-IUGRs (28 days of life and discharge). At 36 weeks PMA 66.0% of VPIs, including all but one of the IUGR patients, were EUGR. Prevalence of PGF at the same time was 67.4% (IUGR patients: 48.1%; non-IUGRs: 70.5% (p = 0.022)). Variables related to PGF at 36 weeks PMA were initial weight loss (%), need for oxygen and lower parenteral lipids in the first week.

CONCLUSIONS

The analysis of z-scores was better suited to identify postnatal growth faltering. PGF could be reduced by minimising initial weight loss and assuring adequate nutrition in patients at risk.

Environmental and birth characteristics as predictors of short stature in early childhood

AIM

To evaluate for environmental and birth characteristic predictors of short stature in a large nationally representative sample.

METHODS

We evaluated 10 127 children from the Early Childhood Longitudinal Study-Kindergarten 2011 cohort, using univariate and multivariable linear and logistic regression to evaluate factors associated with short stature (height <3rd percentile) at kindergarten through second grade. Predictors included birthweight, preterm status, sex, parental education, parental income and race/ethnicity.

RESULTS

Lower birthweight was associated with short stature, with each decreasing kilogram having a 2.45 adjusted odds ratio (aOR; 95% confidence interval [CI] 1.81, 3.33) of short stature for term children in second grade. Preterm children (compared to term children) had an aOR of 2.23 (CI 1.32, 3.78) for short stature. Other predictors of short stature included female sex and lower parental income. African American children had a lower risk of short stature (aOR 0.34, CI 0.14, 0.82) compared to white children.

CONCLUSION

Predictors of short stature include lower birthweight, preterm status, female sex and parental income. Socio-economic disparities and race/ethnicity further influenced height. These data may assist paediatricians in considering contributors to stature outcomes by early school age.

Body composition and cognition in preschool-age children with congenital gastrointestinal anomalies

BACKGROUND

Children with congenital gastrointestinal anomalies (CGIAs) experience multiple stressors while hospitalized in neonatal intensive care units during an essential time of growth and development. Early stress and inadequate nutrition are linked to altered growth patterns and later neurodevelopmental delays. In other at-risk populations, improved fat-free mass (FFM) accretion is associated with improved cognitive outcomes.

OBJECTIVE

To determine if body composition is associated with cognitive function in preschool-age children with CGIAs.

STUDY DESIGN

An observational study examined body composition and cognition in 34 preschool-age children with CGIAs. Anthropometric measurements and body composition testing via air displacement plethysmography were obtained. Measurements were compared with a reference group of healthy, term-born children. Cognition was measured with the NIH Toolbox Early Childhood Cognition Battery. Linear regression was used to test the association of body composition with cognitive function.

RESULTS

Compared with the reference group, children with CGIAs had similar anthropometric measurements (weight, height, and body mass index z-scores) and body composition at preschool-age. Processing speed scores were lower than standardized means (p = 0.001). Increased FFM was associated with higher receptive vocabulary scores (p = 0.001), cognitive flexibility scores (p = 0.005), and general cognitive function scores (p = 0.05).

CONCLUSIONS

At preschool-age, children with CGIAs have similar growth and body composition to their peers. In children with CGIAs, higher FFM was associated with higher cognitive scores. Closer tracking of body composition and interventions aimed at increasing FFM may improve long-term outcomes in this population.

Consequences of early postnatal lipopolysaccharide exposure on developing lungs in mice

Bronchopulmonary dysplasia (BPD) is a chronic lung disease of infants that is characterized by interrupted lung development. Postnatal sepsis causes BPD, yet the contributory mechanisms are unclear. To address this gap, studies have used lipopolysaccharide (LPS) during the alveolar phase of lung development. However, the lungs of infants who develop BPD are still in the saccular phase of development, and the effects of LPS during this phase are poorly characterized. We hypothesized that chronic LPS exposure during the saccular phase disrupts lung development by mechanisms that promote inflammation and prevent optimal lung development and repair. Wild-type C57BL6J mice were intraperitoneally administered 3, 6, or 10 mg/kg of LPS or a vehicle once daily on postnatal days (PNDs) 3-5. The lungs were collected for proteomic and genomic analyses and flow cytometric detection on PND6. The impact of LPS on lung development, cell proliferation, and apoptosis was determined on PND7. Finally, we determined differences in the LPS effects between the saccular and alveolar lungs. LPS decreased the survival and growth rate and lung development in a dose-dependent manner. These effects were associated with a decreased expression of proteins regulating cell proliferation and differentiation and increased expression of those mediating inflammation. While the lung macrophage population of LPS-treated mice increased, the T-regulatory cell population decreased. Furthermore, LPS-induced inflammatory and apoptotic response and interruption of cell proliferation and alveolarization was greater in alveolar than in saccular lungs. Collectively, the data support our hypothesis and reveal several potential therapeutic targets for sepsis-mediated BPD in infants.

Infant Brain Structural MRI Analysis in the Context of Thoracic Non-cardiac Surgery and Critical Care

Objective: To determine brain magnetic resonance imaging (MRI) measures of cerebrospinal fluid (CSF) and whole brain volume of full-term and premature infants following surgical treatment for thoracic non-cardiac congenital anomalies requiring critical care. Methods: Full-term (n = 13) and pre-term (n = 13) patients with long-gap esophageal atresia, and full-term naïve controls (n = 19) < 1 year corrected age, underwent non-sedated brain MRI following completion of thoracic non-cardiac surgery and critical care treatment. Qualitative MRI findings were reviewed and reported by a pediatric neuroradiologist and neurologist. Several linear brain metrics were measured using structural T1-weighted images, while T2-weighted images were required for segmentation of total CSF and whole brain tissue using the Morphologically Adaptive Neonatal Tissue Segmentation (MANTiS) tool. Group differences in absolute (mm, cm³) and normalized (%) data were analyzed using a univariate general linear model with age at scan as a covariate. Mean normalized values were assessed using one-way ANOVA. Results: Qualitative brain findings suggest brain atrophy in both full-term and pre-term patients. Both linear and volumetric MRI analyses confirmed significantly greater total CSF and extra-axial space, and decreased whole brain size in both full-term and pre-term patients compared to naïve controls. Although linear analysis suggests greater ventricular volumes in all patients, volumetric analysis showed that normalized ventricular volumes were higher only in premature patients compared to controls. Discussion: Linear brain metrics paralleled volumetric MRI analysis of total CSF and extra-axial space, but not ventricular size. Full-term infants appear to demonstrate similar brain vulnerability in the context of life-saving thoracic non-cardiac surgery requiring critical care as premature infants.

Neurodevelopmental outcomes following necrotizing enterocolitis

Necrotizing enterocolitis (NEC), a gastrointestinal emergency predominantly affecting premature infants, is associated with increased risk for poor neurodevelopmental outcomes. NEC often strikes during a period of rapid and dynamic neurologic development when the brain is particularly vulnerable to insults and nutrient deficits. The pathogenesis of neurodevelopmental impairment following NEC is likely multifactorial, with both nutritional and non-nutritional factors at play. Follow-up testing that ensures early detection and intervention for impairments is crucial to optimize neurodevelopmental outcomes following NEC. A multifaceted approach to follow-up after NEC is necessary, with close monitoring of growth, serial developmental assessments, neurologic examinations, hearing and vision testing and neuroimaging. Further research is needed to understand the pathogenesis of neurodevelopmental impairment following NEC, to identify more targeted follow-up tests, and to discover interventions aimed at optimizing neurodevelopmental outcomes following NEC.

Former-preterm lambs have persistent alveolar simplification at 2 and 5 months corrected postnatal age

Preterm birth and mechanical ventilation (MV) frequently lead to bronchopulmonary dysplasia, the histopathological hallmark of which is alveolar simplification. How developmental immaturity and ongoing injury, repair, and remodeling impact completion of alveolar formation later in life is not known, in part because of lack of suitable animal models. We report a new model, using former-preterm lambs, to test the hypothesis that they will have persistent alveolar simplification later in life. Moderately preterm lambs (~85% gestation) were supported by MV for ~6 days before being transitioned from all respiratory support to become former-preterm lambs. Results are compared with term control lambs that were not ventilated, and between males (M) and females (F). Alveolar simplification was quantified morphometrically and stereologically at 2 mo (4 M, 4 F) or 5 mo (4 M, 6 F) corrected postnatal age (cPNA) compared with unventilated, age-matched term control lambs (4 M, 4 F per control group). These postnatal ages in sheep are equivalent to human postnatal ages of 1-2 yr and ~6 yr, respectively. Multivariable linear regression results showed that former-preterm lambs at 2 or 5 mo cPNA had significantly thicker distal airspace walls ( P < 0.001 and P < 0.009, respectively), lower volume density of secondary septa ( P < 0.007 and P < 0.001, respectively), and lower radial alveolar count ( P < 0.003 and P < 0.020, respectively) compared with term control lambs. Sex-specific differences were not detected. We conclude that moderate preterm birth and MV for ~6 days impedes completion of alveolarization in former-preterm lambs. This new model provides the opportunity to identify underlying pathogenic mechanisms that may reveal treatment approaches.

The Energy Costs of Prematurity and the Neonatal Intensive Care Unit (NICU) Experience

Premature neonates are in an energy deficient state due to (1) oxygen desaturation and hypoxia events, (2) painful and stressful stimuli, (3) illness, and (4) neurodevelopmental energy requirements. Failure to correct energy deficiency in premature infants may lead to adverse effects such as neurodevelopmental delay and negative long-term metabolic and cardiovascular outcomes. The effects of energy dysregulation and the challenges that clinicians in the Neonatal Intensive Care Unit (NICU) face in meeting the premature infant's metabolic demands are discussed. Specifically, the focus is on the effects of pain and stress on energy homeostasis. Energy deficiency is a complex problem and requires a multi-faceted solution to promote optimum development of premature infants.

Body Composition following Necrotising Enterocolitis in Preterm Infants

BACKGROUND

The optimal nutritional regimen for preterm infants, including those that develop necrotising enterocolitis (NEC), is unknown.

OBJECTIVE

The objective here was to evaluate body composition at term in infants following NEC, in comparison with healthy infants. The primary outcome measure was non-adipose tissue mass (non-ATM).

METHODS

We compared body composition assessed by magnetic resonance imaging at term in infants born <31 weeks of gestational age that participated in NEON, a trial comparing incremental versus immediate delivery of parenteral amino acids on non-ATM, and SMOF versus intralipid on intrahepatocellular lipid content. There were no differences in the primary outcomes. We compared infants that received surgery for NEC (NEC-surgical), infants with medically managed NEC (NEC-medical), and infants without NEC (reference).

RESULTS

A total of 133 infants were included (8 NEC-surgical; 15 NEC-medical; 110 reference). In comparison with the reference group, infants in the NEC-surgical and NEC-medical groups were significantly lighter [adjusted mean difference (95% CI) NEC-surgical: -630 g (-1,010, -210), p = 0.003; NEC-medical: -440 g (-760, -110), p = 0.009] and the total adipose tissue volume (ATV) was significantly lower [NEC-surgical: -360 cm3 (-516, -204), p < 0.001; NEC-medical: -127 cm3 (-251, -4); p = 0.043]. There were no significant differences in non-ATM [adjusted mean difference (95% CI) NEC-surgical: -46 g (-281, 189), p = 0.70; NEC-medical: -122 g (-308, 63), p = 0.20].

CONCLUSION

The lower weight at term in preterm infants following surgically and medically managed NEC, in comparison to preterm infants that did not develop the disease, was secondary to a reduction in ATV. This suggests that the nutritional regimen received was adequate to preserve non-ATM but not to support the normal third-trimester deposition of adipose tissue in preterm infants.

Inadequate preoperative nutrition might be associated with acute kidney injury and greater illness severity postoperatively

OBJECTIVE

Nutrition is vital for maintaining optimal cellular and organ function, particularly in neonates who undergo cardiac surgery. Achieving nutritional goals preoperatively can be challenging because of fluid restrictions, suboptimal oral intake, and concerns for inadequate gastrointestinal circulation. We examined preoperative caloric intake and its effects on postoperative course in neonates who underwent cardiac surgery.

METHODS

We retrospectively reviewed records of neonates (younger than 30 days) who underwent congenital heart surgery requiring cardiopulmonary bypass from 2008 to 2014 at Arnold Palmer Hospital for Children. Data on multiple nutritional and postoperative variables were collected. Study outcomes included hospital length of stay, duration of mechanical ventilation, and acute kidney injury (AKI).

RESULTS

Records of 95 neonates were reviewed. Sixty-six patients (69.5%) with a median age of 5 days did not achieve preoperative caloric goal, whereas 29 patients (30.5%) with a median age of 11 days did. Of those who achieved caloric goal, 6 (20.6%) achieved it via total parental nutrition, 9 (31.1%) with a combination of total parental nutrition and enteral feeds, and 14 (48.3%) via enteral route. There was a significant difference in peak lactate (P = .002), inotropic score (P = .02), and duration of mechanical ventilation (P = .013) between those who did and did not achieve caloric goal. In multivariable analysis we found that failure to achieve caloric goal preoperatively was independently associated with stage 2 or 3 AKI (P = .04; odds ratio, 4.48; 95% confidence interval, 1.02-19.63) and younger age at the time of surgery (P < .001; odds ratio, 0.12; 95% confidence interval, 0.04-0.33).

CONCLUSIONS

Failure to achieve preoperative caloric goal might contribute to development of AKI and might be associated with greater severity of illness postoperatively.

Body Composition Trajectories From Infancy to Preschool in Children Born Premature Versus Full-term

OBJECTIVES

The aim of the study was to longitudinally characterize infancy to preschool body composition trajectories and the association of early fat and fat-free mass gains with preschool age body composition in children born premature versus full-term.

METHODS

A cohort of appropriate-for-gestational age preterm (n = 20) and term (n = 51) infants were followed at 3 visits: "neonatal" visit 1 at 2 weeks of age for term and near term corrected age for preterm; "infancy" visit 2 at 3 to 4 months (preterm corrected age); "preschool" visit 3 at 4 years. Body composition via air displacement plethysmography and anthropometrics were measured at all visits. Tracking of infancy weight and body composition with preschool measurements was tested using Pearson partial correlation coefficients. Associations between serial body composition measurements were assessed using multiple linear regression.

RESULTS

Early differences in body composition between premature (mean gestational age 31.9 weeks, mean birth weight 1843 g) and full-term (mean gestational age 39.8 weeks) infants were not present at preschool age. Visit 1 body composition was not correlated with preschool measurements in the preterm infants. Visit 2 measurements were correlated with preschool measures. Fat-free mass accretion from visit 1 to visit 2 was positively associated with preschool lean mass (β = 0.038, P = 0.049) in preterm children, whereas fat accretion was not associated with preschool body composition.

CONCLUSIONS

Children born prematurely and full-term have similar body composition at preschool age. For preterms infancy fat-free mass gains, and not adiposity gains, are positively associated with preschool fat-free mass; this may be associated with lower risk of later obesity and adverse metabolic outcomes.

Early Elevation in Interleukin-6 is Associated with Reduced Growth in Extremely Low Birth Weight Infants

Objective To determine whether reduced growth velocity (GV) in extremely low birth weight infants is preceded by elevated inflammatory cytokines. Study Design GV was determined at 36 weeks' postmenstrual age (PMA) in 768 infants 401 to 1,000 g birth weight (BW). Association between blood cytokines measured through day of life 21 and GV was explored using linear regression models that adjusted for late-onset sepsis (LOS), BW, small for gestational age (SGA), gender, race, energy intake, and center. Results Serum interleukin-6 (IL-6) was increased at days 14 and 21 in LOS infants. LOS was associated with reduced energy intake and GV for weight (weight-GV) at 36 weeks' PMA. Linear regression analysis controlling for LOS and energy intake showed significant relationships between increased IL-6 at days 14 and 21 with reduced weight-GV at 36 weeks' PMA (p < 0.0001). The relationship between day 21 IL-6 and weight-GV was not associated with LOS (p = 0.12) when controlling for BW and energy intake. Both BW (p = 0.02) and energy intake (p = 0.003) influenced the relationship between day 14 IL-6 and weight-GV. Conclusion IL-6 elevation during the first month of life is associated with lower weight-GV at 36 weeks' PMA and may have a direct effect upon energy balance and postnatal growth.

Impact of placental insufficiency on fetal skeletal muscle growth

Intrauterine growth restriction (IUGR) caused by placental insufficiency is one of the most common and complex problems in perinatology, with no known cure. In pregnancies affected by placental insufficiency, a poorly functioning placenta restricts nutrient supply to the fetus and prevents normal fetal growth. Among other significant deficits in organ development, the IUGR fetus characteristically has less lean body and skeletal muscle mass than their appropriately-grown counterparts. Reduced skeletal muscle growth is not fully compensated after birth, as individuals who were born small for gestational age (SGA) from IUGR have persistent reductions in muscle mass and strength into adulthood. The consequences of restricted muscle growth and accelerated postnatal "catch-up" growth in the form of adiposity may contribute to the increased later life risk for visceral adiposity, peripheral insulin resistance, diabetes, and cardiovascular disease in individuals who were formerly IUGR. This review will discuss how an insufficient placenta results in impaired fetal skeletal muscle growth and how lifelong reductions in muscle mass might contribute to increased metabolic disease risk in this vulnerable population.

Alveolar formation is dysregulated by restricted nutrition but not excess sedation in preterm lambs managed by noninvasive support

BACKGROUND

Preterm birth and respiratory support with invasive mechanical ventilation frequently leads to bronchopulmonary dysplasia (BPD). A hallmark feature of BPD is alveolar simplification. For our preterm lamb model of BPD, invasive mechanical ventilation is associated with postnatal feeding intolerance (reduced nutrition) and sedation. In contrast, preterm lambs managed by noninvasive support (NIS) have normal alveolar formation, appropriate postnatal nutrition, and require little sedation. We used the latter, positive-outcome group to discriminate the contribution of reduced nutrition vs. sedation on alveolar simplification. We hypothesized that, restricted nutrition, but not sedation with pentobarbital, contributes to impaired indices of alveolar formation in preterm lambs managed by NIS.

METHODS

Preterm lambs managed by NIS for 21d were randomized into three groups: NIS control, NIS plus restricted nutrition, and NIS plus excess sedation with pentobarbital. We quantified morphological and biochemical indices of alveolar formation, as well as mesenchymal cell apoptosis and proliferation.

RESULTS

Restricted nutrition impaired morphological and biochemical indices of alveolar formation, and reduced mesenchymal cell apoptosis and proliferation. Excess sedation with pentobarbital did not alter these indices, although mesenchymal cell apoptosis was less.

CONCLUSION

Our results demonstrate that restricted nutrition, but not excess sedation, contributes to impaired alveolar formation during the evolution of BPD in chronically ventilated preterm lambs.

Severe Bronchopulmonary Dysplasia, Growth, Nutrition, and Adipokines at School Age

This study evaluated nutrition and growth in relation to plasma adipokine levels in 21 very-low-birth-weight (VLBW) children with radiographic bronchopulmonary dysplasia (BPD), 19 VLBW controls, and 19 term controls with a median age of 11.3 years. We took anthropometric measurements; assessed plasma levels of adipsin, resistin, adiponectin, and leptin; and analyzed the children’s 3-day food records. Children with BPD had a smaller age-adjusted head circumference and more microcephaly but no other significant growth differences. Daily recommended nutritional intake levels were poorly met but did not differ between the groups. Leptin levels correlated positively with the body mass index standard deviation score in VLBW children. No other associations between adipokine concentrations and growth were found. There were negative correlations between leptin concentrations and fat intake, resistin levels and carbohydrate intake, and adiponectin, adipsin, and leptin levels and energy intake.