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Phongpreecha T, Ghanem M, Reiss JD, Oskotsky TT, Mataraso SJ, De Francesco D, Reincke SM, Espinosa C, Chung P, Ng T, Costello JM, Sequoia JA, Razdan S, Xie F, Berson E, Kim Y, Seong D, Szeto MY, Myers F, Gu H, Feister J, Verscaj CP, Rose LA, Sin LWY, Oskotsky B, Roger J, Shu CH, Shome S, Yang LK, Tan Y, Levitte S, Wong RJ, Gaudillière B, Angst MS, Montine TJ, Kerner JA, Keller RL, Shaw GM, Sylvester KG, Fuerch J, Chock V, Gaskari S, Stevenson DK, Sirota M, Prince LS, Aghaeepour N. AI-guided precision parenteral nutrition for neonatal intensive care units. Nat Med 2025:10.1038/s41591-025-03601-1. [PMID: 40133525 DOI: 10.1038/s41591-025-03601-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2024] [Accepted: 02/17/2025] [Indexed: 03/27/2025]
Abstract
One in ten neonates are admitted to neonatal intensive care units, highlighting the need for precise interventions. However, the application of artificial intelligence (AI) in guiding neonatal care remains underexplored. Total parenteral nutrition (TPN) is a life-saving treatment for preterm neonates; however, implementation of the therapy in its current form is subjective, error-prone and resource-consuming. Here, we developed TPN2.0-a data-driven approach that optimizes and standardizes TPN using information collected routinely in electronic health records. We assembled a decade of TPN compositions (79,790 orders; 5,913 patients) at Stanford to train TPN2.0. In addition to internal validation, we also validated our model in an external cohort (63,273 orders; 3,417 patients) from a second hospital. Our algorithm identified 15 TPN formulas that can enable a precision-medicine approach (Pearson's R = 0.94 compared to experts), increasing safety and potentially reducing cost. A blinded study (n = 192) revealed that physicians rated TPN2.0 higher than current best practice. In patients with high disagreement between the actual prescriptions and TPN2.0, standard prescriptions were associated with increased morbidities (for example, odds ratio = 3.33; P value = 0.0007 for necrotizing enterocolitis), while TPN2.0 recommendations were linked to reduced risk. Finally, we demonstrated that TPN2.0 employing a transformer architecture enabled guideline-adhering, physician-in-the-loop recommendations that allow collaboration between the care team and AI.
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Affiliation(s)
- Thanaphong Phongpreecha
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
- Department of Pathology, Stanford University, Stanford, CA, USA
| | - Marc Ghanem
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Jonathan D Reiss
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Tomiko T Oskotsky
- Bakar Computational Health Sciences Institute, University of California, San Francisco, CA, USA
- Department of Pediatrics, University of California, San Francisco, CA, USA
| | - Samson J Mataraso
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Davide De Francesco
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - S Momsen Reincke
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Camilo Espinosa
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Philip Chung
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
| | - Taryn Ng
- Department of Pharmacy, Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | - Jean M Costello
- Bakar Computational Health Sciences Institute, University of California, San Francisco, CA, USA
| | | | - Sheila Razdan
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- Department of Pediatrics, Keck School of Medicine of USC, Division of Neonatal and Infant Critical Care Unit, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Feng Xie
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Eloise Berson
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
- Department of Pathology, Stanford University, Stanford, CA, USA
| | - Yeasul Kim
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - David Seong
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - May Y Szeto
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Faith Myers
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Hannah Gu
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - John Feister
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | | | - Laura A Rose
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Lucas W Y Sin
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
| | - Boris Oskotsky
- Bakar Computational Health Sciences Institute, University of California, San Francisco, CA, USA
| | - Jacquelyn Roger
- Bakar Computational Health Sciences Institute, University of California, San Francisco, CA, USA
| | - Chi-Hung Shu
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Sayane Shome
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Liu K Yang
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
- Department of Pediatrics, Stanford University, Stanford, CA, USA
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Yuqi Tan
- Department of Pathology, Stanford University, Stanford, CA, USA
- Department of Microbiology and Immunology, Stanford University, Stanford, CA, USA
| | - Steven Levitte
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Stanford University, Stanford, CA, USA
| | - Ronald J Wong
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Brice Gaudillière
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
| | - Martin S Angst
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA
| | | | - John A Kerner
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Roberta L Keller
- Department of Pediatrics, University of California, San Francisco, CA, USA
| | - Gary M Shaw
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Karl G Sylvester
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Janene Fuerch
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Valerie Chock
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Shabnam Gaskari
- Department of Pharmacy, Lucile Packard Children's Hospital, Palo Alto, CA, USA
| | | | - Marina Sirota
- Bakar Computational Health Sciences Institute, University of California, San Francisco, CA, USA
- Department of Pediatrics, University of California, San Francisco, CA, USA
| | | | - Nima Aghaeepour
- Department of Anesthesiology, Pain and Perioperative Medicine, Stanford University, Stanford, CA, USA.
- Department of Pediatrics, Stanford University, Stanford, CA, USA.
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA.
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Ting CS, Tsao PN, Chou HC, Yen TA, Huang HC, Chen CY. Adherence to Nutritional Practice Guideline in Premature Infants: A Nationwide Survey in Taiwan. Nutrients 2024; 16:3181. [PMID: 39339781 PMCID: PMC11434964 DOI: 10.3390/nu16183181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2024] [Revised: 09/16/2024] [Accepted: 09/18/2024] [Indexed: 09/30/2024] Open
Abstract
OBJECTIVES This study aimed to assess the current neonatal nutritional practices in Taiwan and promote consensus on standardized protocols. METHODS An online questionnaire comprising 95 items on parenteral nutrition (PN) and enteral nutrition (EN) practices was distributed to neonatal care units across Taiwan via email between August and December 2022. The responses were compared with the recommendations from the European Society for Pediatric Gastroenterology Hepatology and Nutrition for preterm infant care. RESULTS Most of the 35 neonatal units, comprising 17 level III and 18 level II units, that participated in this study adhered to standard PN protocols; however, only 30% of units used protein-containing solutions as the initial fluid. Over half of the neonatal units provided calcium, phosphate, and magnesium at less than the recommended dosage. Trophic feeding commenced within 48 h in 88% of the units, with the mother's milk used as the first choice. All the units preferred commencing advanced feeding at <25 mL/kg/day. CONCLUSIONS Most nutrient protocols for preterm infants in neonatal units in Taiwan meet recent guidelines, but discrepancies such as lower mineral supplements in PN and a slower advancement of enteral feeding increase nutritional risk. These issues warrant further research.
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Affiliation(s)
- Chi-Shiuan Ting
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei 100, Taiwan; (C.-S.T.); (P.-N.T.); (H.-C.C.); (T.-A.Y.); (H.-C.H.)
- Department of Pediatrics, China Medical University Children’s Hospital, China Medical University, Taichung 404, Taiwan
| | - Po-Nien Tsao
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei 100, Taiwan; (C.-S.T.); (P.-N.T.); (H.-C.C.); (T.-A.Y.); (H.-C.H.)
| | - Hung-Chieh Chou
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei 100, Taiwan; (C.-S.T.); (P.-N.T.); (H.-C.C.); (T.-A.Y.); (H.-C.H.)
| | - Ting-An Yen
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei 100, Taiwan; (C.-S.T.); (P.-N.T.); (H.-C.C.); (T.-A.Y.); (H.-C.H.)
| | - Hsin-Chung Huang
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei 100, Taiwan; (C.-S.T.); (P.-N.T.); (H.-C.C.); (T.-A.Y.); (H.-C.H.)
| | - Chien-Yi Chen
- Department of Pediatrics, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei 100, Taiwan; (C.-S.T.); (P.-N.T.); (H.-C.C.); (T.-A.Y.); (H.-C.H.)
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Shen RL, Ritz C, Li Y, Sangild PT, Jiang PP. Early parenteral nutrition is associated with improved growth in very low birth weight infants: a retrospective study. Arch Dis Child Fetal Neonatal Ed 2024; 109:495-499. [PMID: 38212106 DOI: 10.1136/archdischild-2023-325829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 12/15/2023] [Indexed: 01/13/2024]
Abstract
OBJECTIVE To assess the association between early initiation of parenteral nutrition (PN) and body growth in preterm infants with very low birth weight (VLBW). DESIGN Causal inference analysis with confounders preselected by causal diagram based on the NeoNutriNet cohort containing data of infants born between 2011 and 2014 from 13 hospitals from 5 continents. PATIENTS Neonates with birth weight ≤1500 g. INTERVENTIONS PN initiated within the first day of life (early PN) versus within day 2-5 (delayed PN). MAIN OUTCOME MEASURES The primary outcome was body weight z-scores at postmenstrual age (PMA) 36 weeks or early discharge or death, whichever comes first (WT z-score END). Secondary outcomes included WT z-scores at week 1 and 4 of life (WT z-scores CA1 and CA4), corresponding growth velocities (GVs), mortality and incidence of necrotising enterocolitis (NEC), and duration and episodes of antibiotic treatment. RESULTS In total, 2151 infants were included in this study and 2008 infants were in the primary outcome analysis. Significant associations of early PN were found with WT z-score END (adjusted mean difference, 0.14 (95% CI 0.05 to 0.23)), CA4 (β, 0.09 (0.04 to 0.14)) and CA1 (0.04 (0.01 to 0.08)), and GV PMA 36 weeks (1.02 (0.46 to 1.58)) and CA4 (1.03 (0.56 to 1.49), all p<0.001), but not with GV CA1 (p>0.05). No significant associations with mortality, incidence of NEC or antibiotic use was found (all p>0.05). CONCLUSIONS For VLBW infants, PN initiated within the first day of life is associated with improved in-hospital growth.
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Affiliation(s)
- René Liang Shen
- Department of Veterinary and Animal Sciences, University of Copenhagen, Frederiksberg, Denmark
| | - Christian Ritz
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Yanqi Li
- Department of Veterinary and Animal Sciences, University of Copenhagen, Frederiksberg, Denmark
- NBCD A/S, Søborg, Denmark
| | - Per Torp Sangild
- Department of Veterinary and Animal Sciences, University of Copenhagen, Frederiksberg, Denmark
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Paediatrics, Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Ping-Ping Jiang
- Department of Veterinary and Animal Sciences, University of Copenhagen, Frederiksberg, Denmark
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Dobson NL, Levitt DE, Luk HY, Vellers HL. Adverse Skeletal Muscle Adaptations in Individuals Born Preterm-A Comprehensive Review. Curr Issues Mol Biol 2024; 46:4551-4564. [PMID: 38785544 PMCID: PMC11120075 DOI: 10.3390/cimb46050276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 05/05/2024] [Accepted: 05/08/2024] [Indexed: 05/25/2024] Open
Abstract
Infants born preterm face an increased risk of deleterious effects on lung and brain health that can significantly alter long-term function and quality of life and even lead to death. Moreover, preterm birth is also associated with a heightened risk of diabetes and obesity later in life, leading to an increased risk of all-cause mortality in young adults born prematurely. While these preterm-birth-related conditions have been well characterized, less is known about the long-term effects of preterm birth on skeletal muscle health and, specifically, an individual's skeletal muscle hypertrophic potential later in life. In this review, we discuss how a confluence of potentially interrelated and self-perpetuating elements associated with preterm birth might converge on anabolic and catabolic pathways to ultimately blunt skeletal muscle hypertrophy, identifying critical areas for future research.
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Affiliation(s)
| | - Danielle E. Levitt
- Department of Kinesiology and Sport Management, Texas Tech University, Lubbock, TX 79409, USA
| | - Hui Ying Luk
- Department of Kinesiology and Sport Management, Texas Tech University, Lubbock, TX 79409, USA
| | - Heather L. Vellers
- Department of Kinesiology and Sport Management, Texas Tech University, Lubbock, TX 79409, USA
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Trivedi A, Jatana V, Sinn JK. Early versus late administration of amino acids in preterm infants receiving parenteral nutrition. Cochrane Database Syst Rev 2024; 1:CD008771. [PMID: 38275196 PMCID: PMC10811752 DOI: 10.1002/14651858.cd008771.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
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.
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Affiliation(s)
- Amit Trivedi
- Grace Centre for Newborn Intensive Care, The Children's Hospital at Westmead, Westmead, Australia
- The University of Sydney, Sydney, Australia
| | - Vishal Jatana
- Helen MacMillan Paediatric Intensive Care Unit, The Children's Hospital at Westmead, Westmead, Australia
| | - John Kh Sinn
- Department of Neonatology, Royal North Shore Hospital, The University of Sydney, Sydney, Australia
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Harman JC, Pivodic A, Nilsson AK, Boeck M, Yagi H, Neilsen K, Ko M, Yang J, Kinter M, Hellström A, Fu Z. Postnatal hyperglycemia alters amino acid profile in retinas (model of Phase I ROP). iScience 2023; 26:108021. [PMID: 37841591 PMCID: PMC10568433 DOI: 10.1016/j.isci.2023.108021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/03/2023] [Accepted: 09/19/2023] [Indexed: 10/17/2023] Open
Abstract
Nutritional deprivation occurring in most preterm infants postnatally can induce hyperglycemia, a significant and independent risk factor for suppressing physiological retinal vascularization (Phase I retinopathy of prematurity (ROP)), leading to compensatory but pathological neovascularization. Amino acid supplementation reduces retinal neovascularization in mice. Little is known about amino acid contribution to Phase I ROP. In mice modeling hyperglycemia-associated Phase I ROP, we found significant changes in retinal amino acids (including most decreased L-leucine, L-isoleucine, and L-valine). Parenteral L-isoleucine suppressed physiological retinal vascularization. In premature infants, severe ROP was associated with a higher mean intake of parenteral versus enteral amino acids in the first two weeks of life after adjustment for treatment group, gestational age at birth, birth weight, and sex. The number of days with parenteral amino acids support independently predicted severe ROP. Further understanding and modulating amino acids may help improve nutritional intervention and prevent Phase I ROP.
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Affiliation(s)
- Jarrod C. Harman
- Department of Ophthalmology, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Aldina Pivodic
- The Sahlgrenska Centre for Pediatric Ophthalmology Research, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anders K. Nilsson
- The Sahlgrenska Centre for Pediatric Ophthalmology Research, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Myriam Boeck
- Department of Ophthalmology, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Hitomi Yagi
- Department of Ophthalmology, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Ophthalmology, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Katherine Neilsen
- Department of Ophthalmology, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Minji Ko
- Department of Ophthalmology, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Jay Yang
- Department of Ophthalmology, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Michael Kinter
- Oklahoma Medical Research Foundation, Oklahoma City, OK 73104, USA
| | - Ann Hellström
- The Sahlgrenska Centre for Pediatric Ophthalmology Research, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Zhongjie Fu
- Department of Ophthalmology, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
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Abstract
Prematurity and other complications at birth are nutritional emergencies. Parenteral nutrition is a bridge to enteral nutrition for a few days or months, and sometimes the sole source of nutrition for life. Parenteral nutrition regimens are constructed to provide adequate and balanced energy, macronutrients, and micronutrients to support growth and prevent deficiencies. Neonatal parenteral nutrition regimens are complicated by periodic shortages of essential products, compatibility challenges, and contaminants. Newborns benefit from serial growth assessments, monitoring of biochemical status, nutrition-focused physical examinations, and management by a multidisciplinary team to ensure adequacy of parenteral nutrition and promote best outcomes.
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Affiliation(s)
- Sharon Groh-Wargo
- Nutrition and Pediatrics, Case Western Reserve University at MetroHealth Medical Center, 2500 MetroHealth Drive, C.G72, Cleveland, OH 44109-1998, USA
| | - Stephanie Merlino Barr
- Neonatal Dietitian, Department of Pediatrics, MetroHealth Medical Center, 2500 MetroHealth Drive, C.G72, Cleveland, OH 44109-1998, USA.
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Ambreen G, Kumar V, Ali SR, Jiwani U, Khowaja W, Hussain AS, Hussain K, Raza SS, Rizvi A, Ansari U, Ahmad K, Demas S, Ariff S. Impact of a standardised parenteral nutrition protocol: a quality improvement experience from a NICU of a developing country. Arch Dis Child 2022; 107:381-386. [PMID: 34257078 DOI: 10.1136/archdischild-2021-321552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 06/21/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Nutrition societies recommend using standardised parenteral nutrition (SPN) solutions. We designed evidence-based SPN formulations for neonates admitted to our neonatal intensive care unit (NICU) and evaluated their outcomes. DESIGN This was a quality improvement initiative. Data were collected retrospectively before and after the intervention. SETTING A tertiary-care level 3 NICU at the Aga Khan University in Karachi, Pakistan. PATIENTS All NICU patients who received individualised PN (IPN) from December 2016 to August 2017 and SPN from October 2017 to June 2018. INTERVENTIONS A team of neonatologists and nutrition pharmacists collaborated to design two evidence-based SPN solutions for preterm neonates admitted to the NICU. MAIN OUTCOME MEASURES We recorded mean weight gain velocity from days 7 to 14 of life. The other outcomes were change in weight expressed as z-scores, metabolic abnormalities, PN-associated liver disease (PNALD), length of NICU stay and episodes of sepsis during hospital stay. RESULTS Neonates on SPN had greater rate of change in weight compared with IPN (β=13.40, 95% CI: 12.02 to 14.79) and a smaller decrease in z-scores (p<0.001). Neonates in the SPN group had fewer hyperglycemic episodes (IPN: 37.5%, SPN: 6.2%) (p<0.001), electrolyte abnormalities (IPN: 56.3%, SPN: 21%) (p<0.001), PNALD (IPN: 52.5%, SPN: 18.5%) (p<0.001) and sepsis (IPN: 26%, SPN: 20%) (p<0.05). The median length of stay in NICU was 14.0 (IQR 12.0-21.0) for the IPN and 8.0 (IQR 5.0-13.0) days for the SPN group. CONCLUSIONS We found that SPN was associated with shorter NICU stay and greater weight gain. In-house preparation of SPN can be used to address the nutritional needs in resource-limited settings where commercially prepared SPN is not available.
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Affiliation(s)
- Gul Ambreen
- Department of Pharmacy, Aga Khan University Hospital, Karachi, Pakistan
| | - Vikram Kumar
- Neonatology, Indus Hospital and Health Network, Karachi, Sindh, Pakistan
| | - Syed Rehan Ali
- Neonatology, Indus Hospital and Health Network, Karachi, Sindh, Pakistan
| | - Uswa Jiwani
- Center of Excellence in Women and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Waqar Khowaja
- Department of Paediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Ali Shabbir Hussain
- Department of Paediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Kashif Hussain
- Department of Pharmacy, Aga Khan University Hospital, Karachi, Pakistan
| | - Syed Shamim Raza
- Department of Pharmacy, Aga Khan University Hospital, Karachi, Pakistan
| | - Arjumand Rizvi
- Department of Paediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Uzair Ansari
- Department of Paediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Khalil Ahmad
- Department of Paediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Simon Demas
- Department of Paediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Shabina Ariff
- Department of Paediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
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Parramón-Teixidó CJ, Gómez-Ganda L, Garcia-Palop B, Linés-Palazón M, Blanco-Grau A, Montoro-Ronsano JB, Clemente-Bautista S. The influence of parenteral protein intake on electrolyte disturbances in premature infants. An Pediatr (Barc) 2021; 95:139-146. [PMID: 34507648 DOI: 10.1016/j.anpede.2020.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 03/28/2020] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Aggressive parenteral nutrition with delivery of high amino acid and energy doses is used to improve growth and neurodevelopmental outcomes in very low birth weight (VLBW) preterm infants. Recent findings, however, suggest that this approach may cause electrolyte imbalances. The aim of our study was to compare the prevalence of hypercalcaemia, hypophosphataemia, and hypokalaemia in 2 groups of preterm infants that received parenteral nutrition with different amounts of amino acids and to analyse perinatal and nutritional variables associated with the development of electrolyte imbalances. METHODS We conducted a retrospective observational study comparing 2 groups of preterm infants born before 33 weeks' gestation with birth weights of less than 1500 g managed with parenteral nutrition. One of the groups received less than 3 g/kg/day of amino acids and the other received 3 g/kg//day of amino acids or more. We analysed the prevalence of electrolyte imbalances and possible associations with aggressive parenteral nutrition, adjusting for potential confounders. RESULTS We studied 114 infants: 60 given less than 3 g/kg/day of amino acids (low-intake group) and 54 given at least 3 g/kg/day (high-intake group). The prevalence of electrolyte imbalances was similar in both groups. The prevalence of hypercalcaemia was 1.67% in the low-intake group and 1.85% in the high-intake group (P > .99), the prevalence of severe hypophosphataemia 11.7% vs 9.3%, and the prevalence of hypokalaemia 15.0% vs 11.1% (P > .99). A calcium to phosphorus ratio greater than 1.05 had a protective effect against hypophosphataemia (P = .007). CONCLUSIONS We did not find an association between hypercalcaemia, hypophosphataemia, and hypokalaemia and the amino acid dose delivered by PN in the high-intake group of preterm infants.
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Affiliation(s)
| | - Laura Gómez-Ganda
- Pharmacy Service, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | | | | | - Albert Blanco-Grau
- Clinical Laboratory, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
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10
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Influencia del aporte proteico parenteral en las alteraciones electrolíticas en recién nacidos prematuros. An Pediatr (Barc) 2021. [DOI: 10.1016/j.anpedi.2020.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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11
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Jiang YN, Ye YX, Sangild PT, Thymann T, Engelsen SB, Khakimov B, Jiang PP. Plasma Metabolomics to Evaluate Progression of Necrotising Enterocolitis in Preterm Pigs. Metabolites 2021; 11:metabo11050283. [PMID: 33946896 PMCID: PMC8146597 DOI: 10.3390/metabo11050283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/19/2021] [Accepted: 04/26/2021] [Indexed: 02/04/2023] Open
Abstract
Necrotising enterocolitis (NEC) is a microbiome-dependent gut disease in preterm infants in early life. Antibiotic treatment is a common intervention for NEC. How NEC lesions, with or without antibiotics, affect plasma metabolome was explored in this study. Formula-fed preterm pigs were used as a model for human NEC and treated with saline, parenteral or oral antibiotics (n = 15-17) for four days after delivery. Gut tissues were collected for evaluation of NEC-like lesions and plasma for metabolomic analysis by proton nuclear magnetic resonance spectroscopy (1H-NMR). Metabolites were annotated, quantified and subjected to statistical modelling to delineate the effects of NEC and antibiotic treatment. Presence of severe NEC lesions, not antibiotic treatment, was the main drive for plasma metabolite changes. Relative to other pigs, pigs with severe NEC lesions had higher levels of alanine, histidine and myo-inositol, and lower levels of 3-hydroxybutyric acid and isobutyric acid. Across NEC lesion states (healthy, mild, severe), antibiotics directly affected only a few metabolites (tryptophan, 3-phenyllactic acid). Together and independently, NEC and antibiotic treatment affected circulating metabolites in preterm pigs. Amino acids and plasma metabolites, partly related to the gut microbiome, may be helpful to monitor progression of NEC lesions after proper validation.
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Affiliation(s)
- Yan-Nan Jiang
- School of Public Health, Sun Yat-sen University, Guangzhou 510080, China; (Y.-N.J.); (Y.-X.Y.)
| | - Yong-Xin Ye
- School of Public Health, Sun Yat-sen University, Guangzhou 510080, China; (Y.-N.J.); (Y.-X.Y.)
| | - Per Torp Sangild
- Section for Comparative Paediatrics and Nutrition, Department of Veterinary and Animal Sciences, University of Copenhagen, DK-1870 Frederiksberg, Denmark; (P.T.S.); (T.T.)
- Department of Neonatology, Rigshospitalet, DK-2100 Copenhagen, Denmark
- Department of Paediatrics, Odense University Hospital, DK-5000 Odense, Denmark
| | - Thomas Thymann
- Section for Comparative Paediatrics and Nutrition, Department of Veterinary and Animal Sciences, University of Copenhagen, DK-1870 Frederiksberg, Denmark; (P.T.S.); (T.T.)
| | - Søren Balling Engelsen
- Department of Food Science, University of Copenhagen, DK-1958 Frederiksberg, Denmark; (S.B.E.); (B.K.)
| | - Bekzod Khakimov
- Department of Food Science, University of Copenhagen, DK-1958 Frederiksberg, Denmark; (S.B.E.); (B.K.)
| | - Ping-Ping Jiang
- School of Public Health, Sun Yat-sen University, Guangzhou 510080, China; (Y.-N.J.); (Y.-X.Y.)
- Section for Comparative Paediatrics and Nutrition, Department of Veterinary and Animal Sciences, University of Copenhagen, DK-1870 Frederiksberg, Denmark; (P.T.S.); (T.T.)
- Correspondence:
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12
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Zhao X, Ding L, Chen X, Zhu X, Wang J. Characteristics and risk factors for extrauterine growth retardation in very-low-birth-weight infants. Medicine (Baltimore) 2020; 99:e23104. [PMID: 33217811 PMCID: PMC7676529 DOI: 10.1097/md.0000000000023104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND To investigate the characteristics and risk factors for extrauterine growth retardation (EUGR) in very-low-birth-weight infants (VLBWIs). METHODS The medical records of 137 VLBWIs admitted to the neonatal intensive care unit between June 2015 and December 2017 were retrospectively reviewed. The patients were divided into EUGR (n = 92) and non-EUGR (n = 45) groups. This study collected data on demographic and clinical characteristics and analyzed the risk factors for EUGR with multivariate logistic regression. RESULTS Gestational age (OR = 0.573, P < .01), SGA (OR = 3.887, P = .022), feeding intolerance (OR = 4.632, P = .002), and calories supplied by amino acids at the 7th day (OR = 0.786, P = .006) were high-risk factors for EUGR. CONCLUSION Feeding intolerance reduction and amino acid nutrition support should be applied to prevent delayed extrauterine growth for VLBWIs.
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Affiliation(s)
| | | | | | | | - Jian Wang
- Department of Neonatology Surgery, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
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13
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Yakubovich D, Strauss T, Ohana D, Taran C, Snapiri O, Karol DL, Starez-Chaham O, Kochavi B, Tsur A, Morag I. Factors associated with early phosphate levels in preterm infants. Eur J Pediatr 2020; 179:1529-1536. [PMID: 32248319 DOI: 10.1007/s00431-020-03622-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 02/20/2020] [Accepted: 02/25/2020] [Indexed: 12/01/2022]
Abstract
To investigate perinatal factors and early morbidities associated with early serum phosphate (sPhos) levels in a cohort of preterm infants. Retrospective data were obtained from the medical records of a cohort of 454 infants born at < 32 weeks gestational age. Serum phosphate levels were directly associated with gestational age, body weight z-score, and Apgar scores and inversely associated with timing of enteral nutrition initiation and diet consisting of mostly breast milk. Maternal hypertension, lactate levels, early symptomatic hypotension, and total protein supplemented on days 1 to 3 were also inversely associated with sPhos. Morbidities that were found to be associated with sPhos did not persist after adjustment for confounding factors.Conclusions: We report a novel association between early sPhos and timing and content of enteral nutrition, as well as with the early neonatal hemodynamic condition of preterm infants. This information may help identify infants at risk for low sPhos and aid in the nutritional strategy utilized in these patients. This study did not identify early morbidities associated with sPhos. What is Known: • High initial amino acid intake is associated with increased risk of Refeeding like syndrome and hypophosphatemia, among preterm infants. What is New: • Early enteral nutrition, starting within the first 72 h of life, is associated with higher serum phosphate (sPhos) compared to nothing per os (NPO). • sPhos was not associated with early adverse neonatal outcomes.
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Affiliation(s)
- Daniel Yakubovich
- Department of Pediatrics, Schneider Children's Medical Center, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Tzipi Strauss
- Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel.,Department of Pediatrics, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Dror Ohana
- Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Camelia Taran
- Department of Pediatrics, Grigore Alexandrescu Emergency Clinical Hospital for Children in Bucharest, București, Romania
| | - Ori Snapiri
- Department of Pediatrics, Schneider Children's Medical Center, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | | | - Orna Starez-Chaham
- Department of Neonatology, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Briggite Kochavi
- Department of Pediatrics, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Abraham Tsur
- Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel.,Department of Obstetrics and Gynecology, Stanford University, Stanford, CA, USA.,Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Iris Morag
- Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel. .,Department of Pediatrics, Shamir Medical Center, 70300, Zerifin, Israel.
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14
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Martínez-Jiménez MD, Gómez-García FJ, Gil-Campos M, Pérez-Navero JL. Comorbidities in childhood associated with extrauterine growth restriction in preterm infants: a scoping review. Eur J Pediatr 2020; 179:1255-1265. [PMID: 32096070 DOI: 10.1007/s00431-020-03613-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 02/11/2020] [Accepted: 02/12/2020] [Indexed: 11/30/2022]
Abstract
Extrauterine growth restriction (EUGR) is a frequent morbidity of preterm infants that can affect short- and long-term prognosis as it involves different EUGR-related alterations in growth and neurological development, as well as cardiometabolic risk. However, knowledge about the prognosis of EUGR is scarce. Thus, the objective of this study is to review the evidence regarding EUGR-related comorbidities in childhood by a systematic approach. This review was carried out using the Joanna Briggs Institute Reviewers' Manual Methodology and the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses)-Search Extension for scoping review. The MEDLINE and EMBASE databases were used to identify papers published until September 2017. Twenty-four publications were included and 19 examined cohort studies. EUGR is mainly associated with (1) lower weight, length, and head circumference measures in childhood; (2) poor neurodevelopment; and (3) alterations in cardiometabolic risk markers. The definition for EUGR and the populations studied differ among authors.Conclusion: EUGR is mainly associated with poor growth and neurodevelopment, as well as with cardiometabolic alterations in childhood. Evidence is based on observational studies with variability in the included populations due to the lack of consensus regarding the definition for EUGR. Finding a gold standard definition becomes paramount in order to select phenotypes at risk later in life. What is known? • EUGR is a frequent condition of preterm infants. Up to date little is known about the effect of the metabolic programming on prognosis. What is new? • The available evidence, which is based on observational studies with variability in the population and the existing different definitions for EUGR, do not enable appropriate data collection. EUGR is mainly associated with poor growth and neurodevelopment, as well as with cardiometabolic alterations in childhood.
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Affiliation(s)
- M D Martínez-Jiménez
- Neonatology Unit. Reina Sofia University Hospital; Pediatric Research Unit, Maimónides Biomedical Research Institute of Córdoba (IMIBIC), University of Córdoba, Córdoba, Spain
| | - F J Gómez-García
- Maimónides Biomedical Research Institute of Córdoba (IMIBIC), University of Córdoba, Córdoba, Spain
| | - M Gil-Campos
- Pediatric Research Unit, Reina Sofia University Hospital Maimónides Biomedical Research Institute of Córdoba (IMIBIC), CIBERObn, University of Córdoba, Avda. Menéndez Pidal sn, 14004, Córdoba, Spain.
| | - J L Pérez-Navero
- Department of Pediatrics, Reina Sofia University Hospital; Pediatric Research Unit, Maimónides Biomedical Research Institute of Córdoba (IMIBIC), CIBERER, University of Córdoba, Córdoba, Spain
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15
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Levene I, McCormick K. Improved growth of extremely and very preterm babies: Evaluation of a quality-of-care initiative. J Paediatr Child Health 2020; 56:444-449. [PMID: 31774596 DOI: 10.1111/jpc.14662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 08/29/2019] [Accepted: 09/09/2019] [Indexed: 11/28/2022]
Abstract
AIM To measure growth outcomes in preterm infants after introduction of a nutritional care bundle. METHODS A total of 509 infants of less than 32 weeks' gestation in a level III neonatal intensive care unit in the UK were studied until they were discharged home. Growth and feeding data were extracted from a prospective data registry for 18 months before and after the intervention. The intervention consisted of earlier routine bovine-derived multi-component fortification once the infant has reached 120ml/kg/day of enteral feed from the first day of life and an exclusive human milk diet with routine bovine-derived multi-component fortification of 120 mL/kg/day. RESULTS After the intervention, growth velocity between birth and 28 days increased from 9.7 ± 4.1 to 12.2 ± 4.6 g/kg/day (mean ± standard deviation), and weight z score change decreased from -1.06 ± 0.56 to -0.76 ± 0.59 (P < 0.00002). For the entire group, growth velocity by the discharge home time point increased by 1 g/kg/day. However, the growth velocity of infants who were discharged on an exclusive human milk diet increased the most, from 10.8 ± 2.2 to 13.0 ± 2.8 g/kg/day (P < 0.00001), eliminating the difference seen between these infants and those discharged on infant formula before the intervention. CONCLUSION The introduction of a simple nutritional package improved weight gain, particularly in infants fed exclusive human milk at discharge.
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Affiliation(s)
- Ilana Levene
- Newborn Care Unit, John Radcliffe Hospital, Oxford, United Kingdom
| | - Kenny McCormick
- Newborn Care Unit, John Radcliffe Hospital, Oxford, United Kingdom
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16
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Zhang J, Xu W, Han H, Zhang L, Wang T. Dietary Leucine Supplementation Restores Serum Glucose Levels, and Modifying Hepatic Gene Expression Related to the Insulin Signal Pathway in IUGR Piglets. Animals (Basel) 2019; 9:ani9121138. [PMID: 31847151 PMCID: PMC6941017 DOI: 10.3390/ani9121138] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 12/09/2019] [Accepted: 12/11/2019] [Indexed: 12/15/2022] Open
Abstract
Simple Summary Intrauterine malnutrition may compromise the size and structure of fetal organs and tissues, which leads to lower birth weight and a slower rate of growth after weaning. Intrauterine growth restriction/retardation (IUGR) impairs pancreas function, resulting in the decreased glucose levels in serum. Leucine, one of branched chain amino acids, is an essential amino acid and the substrate of protein synthesis. Leucine also acts as a major regulator of hormone signal transduction, like insulin. Dietary branched chain amino acids or leucine have beneficial effects on the glucose metabolism and glycogen synthesis of muscle. Leucine supplementation improves the insulin sensitivity in liver and muscle and then influences the systemic glucose homeostasis. However, it is still unclear whether leucine supplementation would alter insulin sensitivity in IUGR neonatal piglets. Our results showed that dietary leucine supplementation restored serum glucose concentrations, increased insulin and creatinine concentrations, and enhanced protein kinase adenosine monophosphate-activated γ 3-subunit and glucose transporter type 2 expression. These findings suggest that leucine might play a positive role in hepatic lipid metabolism and glucose metabolism in IUGR. Abstract This study aimed to investigate the effects of leucine with different levels on the insulin resistance in intrauterine growth restriction/retardation (IUGR) piglets. Thirty-two weaned piglets were arranged in a 2 × 2 factorial design and four treatments (n = 8) were as follow: (1) normal weaned piglets fed a basal diet (CONT), (2) IUGR weaned piglets fed a basal diet (IUGR), (3) normal weaned piglets fed a basal diet with the addition of 0.35% l-leucine (C-LEU), and (4) IUGR fed a basal diet with the addition of 0.35% l-leucine (I-LEU) for a 21-days trial. The results showed that compared to the IUGR group, the I-LEU group had higher final body weight and body weight gain, higher serum glucose concentrations, and higher serum insulin concentrations (p < 0.05). The gene expression of phosphatidylinositol 3-kinase p110 gamma, protein kinase adenosine monophosphate-activated γ 3-subunit, glycogen synthase kinase-3 alpha, and glucose transporter type 2 were increased in the I-LEU group as compared to the IUGR group (p < 0.05). It was concluded that dietary leucine supplementation restored serum glucose concentrations, increased insulin and creatinine concentrations, and enhanced protein kinase adenosine monophosphate-activated γ 3-subunit and glucose transporter type 2 expression, suggesting that leucine might play a positive role in hepatic lipid metabolism and glucose metabolism in IUGR.
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Affiliation(s)
| | | | | | | | - Tian Wang
- Correspondence: ; Tel./Fax: +86-25-84395156
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Power VA, Spittle AJ, Lee KJ, Anderson PJ, Thompson DK, Doyle LW, Cheong JLY. Nutrition, Growth, Brain Volume, and Neurodevelopment in Very Preterm Children. J Pediatr 2019; 215:50-55.e3. [PMID: 31561956 DOI: 10.1016/j.jpeds.2019.08.031] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 06/30/2019] [Accepted: 08/15/2019] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To explore the associations between nutrition in the first 28 days after birth with somatic growth from birth to term-equivalent age, brain volumes at term-equivalent age, and neurodevelopment at 24 months of corrected age. STUDY DESIGN Prospective cohort study of 149 infants born from 2011 to 2014 at <30 weeks of gestation in a tertiary neonatal nursery in Australia. The following data were collected: average daily energy, protein, fat, and carbohydrate intakes from birth until 28 days, and the difference in weight and head circumference z scores between birth and term-equivalent. Total brain tissue volumes were calculated from brain magnetic resonance imaging at term-equivalent age. Children were assessed at 2 years of corrected age with the Bayley Scales of Infant and Toddler Development-Third Edition. Relationships of nutritional variables with growth, brain volumes, and cognitive, language, and motor development were explored using linear regression. RESULTS Complete nutritional data were available for 116 (78%) of the cohort. A 1 g/kg/day higher mean protein intake was associated with a mean increase in weight z score per week of 0.05 (95% CI 0.05, 0.10; P = .04). There was a lack of evidence for associations of any nutritional variables with head circumference growth, with brain volumes at term-equivalent age, or with 2-year neurodevelopment. CONCLUSIONS Only higher protein intakes in the first 28 days after birth were associated with better weight growth between birth and term-equivalent age in very preterm infants. Nutrition in the first 28 days was otherwise not substantially related to brain size or to neurodevelopmental outcomes.
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Affiliation(s)
- Victoria A Power
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Alicia J Spittle
- Department of Physiotherapy, University of Melbourne, Melbourne Australia; Victorian Infant Brain Studies, Murdoch Children's Research Institute, Melbourne Australia
| | - Katherine J Lee
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne Australia; Department of Pediatrics, University of Melbourne, Melbourne Australia
| | - Peter J Anderson
- Victorian Infant Brain Studies, Murdoch Children's Research Institute, Melbourne Australia; Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne Australia
| | - Deanne K Thompson
- Victorian Infant Brain Studies, Murdoch Children's Research Institute, Melbourne Australia; Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne Australia; Developmental Imaging, Murdoch Children's Research Institute, Melbourne Australia; Florey Institute of Neurosciences and Mental Health, Melbourne, Australia
| | - Lex W Doyle
- Victorian Infant Brain Studies, Murdoch Children's Research Institute, Melbourne Australia; Department of Pediatrics, University of Melbourne, Melbourne Australia; Department of Obstetrics and Gynecology, University of Melbourne, Melbourne, Australia; Neonatal Services, Royal Women's Hospital, Parkville, Australia
| | - Jeanie L Y Cheong
- Victorian Infant Brain Studies, Murdoch Children's Research Institute, Melbourne Australia; Department of Obstetrics and Gynecology, University of Melbourne, Melbourne, Australia; Neonatal Services, Royal Women's Hospital, Parkville, Australia.
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Abdou RM, Weheiba HMI. The effect of early versus late lipid infusion in parenteral nutrition on the biochemical and cortical auditory evoked potential parameters in preterm neonates. EGYPTIAN PEDIATRIC ASSOCIATION GAZETTE 2019. [DOI: 10.1186/s43054-019-0006-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
As brain activity depends greatly on the functions provided by lipid membranes, dietary fat in early life can affect the developing nervous system. Despite the adoption of an early more aggressive parenteral nutrition approach with amino acid infusions still reluctance to the early use of intravenous lipids in neonates.
Aim
To compare the effect of delayed versus early introduction of intravenous lipid in preterm on the biochemical parameters and on brain development by the cortical auditory evoked potential (CAEP) latency and amplitude.
Methods
This is a comparative study included 49 neonates admitted at the ain shams university NICUs. Participants were divided into two groups: 26 in group of early lipid infusion and 23 in late lipid infusion, Demographic data, and biochemical parameters were documented during the 1st 2 weeks of life. The CAEP was performed at age of 6 months. The latency and amplitude of P1 were recorded and compared between both groups.
Results
In the present work we found that group of early lipid infusion had reach their full oral intake earlier with shorter duration of parenteral nutrition and length of stay. They had better weight gain and significantly better glucose level control than group of late lipid infusion. There was no significant difference in the other chemical parameters between both groups expect for the higher incidence of cholestasis in the group of late lipid infusion. At 6 months of age, the group of early lipid infusion had significantly shorter latency and amplitude of P1 than the group of late lipid infusion.
Conclusion
Early effective nutrition positively affect feeding tolerance and weight gain and maturation of higher brain centers brain.
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Algorithm for Calculating the Protein Intake in Enteral and Parenteral Nutrition in Premature Infants. CURRENT HEALTH SCIENCES JOURNAL 2019; 44:157-165. [PMID: 30746164 PMCID: PMC6320467 DOI: 10.12865/chsj.44.02.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 03/27/2018] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Calculating the exact nutritional balance especially for the premature infant has always been a challenge for the daily practice of the clinician. PURPOSE we intend to establish a simplified formula and mathematical algorithms to calculate the necessary amino acids and proteins for the nutrition of the premature newborn, covering most of the international recommendations and also to give to the neonatal intensive care physician the opportunity of their rapid customization for each case. METHODS following an extensive literature revision we have established the protein intake recommendations, indications and contraindications for enteral and parenteral nutrition in premature infants, by age of gestation, birth weight and postnatal age. Then, these recommendations were translated into simplified mathematical equations and we have proceeded to develop logical algorithms to enable the rapid choice of the best equation that fits each individual case with all its peculiarities, at a defined time. RESULTS for all three premature categories, we have identified intervals for enteral and parenteral nutrition, which were translated into mathematical formulas and management regulations and then transposed into logic algorithms. CONCLUSIONS although mathematically one can use a simplified calculation, for a rapid appreciation, the clinician is still required to go through these algorithms daily and sometimes several times a day. Moreover, to optimize protein intake, we have to calculate the protein / energy ratio and the non-protein calories / gram of protein ratio. This involves extending the calculation for the carbohydrates, fats and calories-practically the entire nutrition.
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ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Amino acids. Clin Nutr 2018; 37:2315-2323. [DOI: 10.1016/j.clnu.2018.06.945] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 05/29/2018] [Indexed: 02/02/2023]
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Choi JW, Kim J, Ahn SY, Chang YS, Park WS, Sung SI. Tolerability and Effect of Early High-Dose Amino Acid Administration in Extremely Low Birth Weight Infants. NEONATAL MEDICINE 2018. [DOI: 10.5385/nm.2018.25.4.153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Hu F, Tang Q, Wang Y, Wu J, Ruan H, Lu L, Tao Y, Cai W. Analysis of Nutrition Support in Very Low-Birth-Weight Infants With Extrauterine Growth Restriction. Nutr Clin Pract 2018; 34:436-443. [PMID: 30421458 PMCID: PMC7379204 DOI: 10.1002/ncp.10210] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Objective To assess the incidence of extrauterine growth restriction (EUGR) in very low‐birth‐weight infants (VLBWIs) and evaluate the nutrition factors in VLBWIs associated with inadequate nutrient intakes during hospitalization. Methods A total of 128 VLBWIs were divided into an EUGR group (n = 87) and a non‐EUGR group (n = 41). Growth and parenteral nutrition (PN) and enteral nutrition (EN) practices were analyzed. Actual energy and protein intakes were subtracted from recommended energy (120 kcal/kg/d) and protein (3.75 g/kg/d) intakes, and nutrition deficits were calculated. Results Growth restriction was 21.9% at birth and 68.0% at discharge. Compared with established guidelines, PN was started late, and the maximum amino acid intake was low in both groups. EN interruption rate was higher in the EUGR group. The average energy intake in the first day after PN termination was lower in the EUGR group. There were significant differences in actual energy and protein intakes in the 2 groups for several weeks during hospitalization. The cumulative energy and protein deficits were significantly higher in the first 8 weeks and during the third to seventh weeks in the EUGR group, respectively. Step regression analysis showed that there was a significant negative correlation between the cumulative deficit of energy and changes of weight z‐scores (r = −0.001, P < .05): as the energy deficit loss increased by 100 kcal, the weight z‐scores dropped by 0.1 SD. Conclusion Inadequate nutrition intake aggravated the occurrence of EUGR in VLBWIs, especially the energy intake.
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Affiliation(s)
- Fangwen Hu
- Department of Clinical Nutrition, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qingya Tang
- Department of Clinical Nutrition, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
| | - Ying Wang
- Department of Clinical Nutrition, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiang Wu
- Department of Clinical Nutrition, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Huijuan Ruan
- Department of Clinical Nutrition, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lina Lu
- Department of Clinical Nutrition, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yijing Tao
- Department of Clinical Nutrition, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei Cai
- Department of Clinical Nutrition, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
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Lenhartova N, Matasova K, Lasabova Z, Javorka K, Calkovska A. Impact of early aggressive nutrition on retinal development in premature infants. Physiol Res 2018; 66:S215-S226. [PMID: 28937236 DOI: 10.33549/physiolres.933677] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The normal retinal development is interrupted by preterm birth and a retinopathy of prematurity (ROP) may develop as its consequence. ROP is characterized by aberrant vessel formation in the retina as a response to multiple risk factors influencing the process of retinal angiogenesis. Insulin-like growth factor I (IGF-1) and vascular endothelial growth factor (VEGF) play an important role in the process of normal retinal vascularization. Insufficient nutrition during the first 4 postnatal weeks results in low serum levels of IGF-1, which is essential for correct retinal vessels formation, ensuring survival of the newly formed endothelial cells. Low IGF-1 level results in stop of angiogenesis in the retina, leaving it avascular and prompting the onset of ROP. Keeping the newborns in a positive energetic balance by providing enough nutrients and energy has a beneficial impact on their growth, neurodevelopment and decreased incidence of ROP. The best way to achieve this is the early parenteral nutrition with the high content of nutrients combined with early enteral feeding by the own mother´s breast milk. Multiple studies confirmed the safety and efficacy of early aggressive nutrition but information about its long-term effects on the metabolism, growth and development is still needed.
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Affiliation(s)
- N Lenhartova
- Clinic of Neonatology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, University Hospital, Martin, Slovakia.
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Riskin A. Meeting the nutritional needs of premature babies: their future is in our hands. Br J Hosp Med (Lond) 2017; 78:690-694. [PMID: 29240511 DOI: 10.12968/hmed.2017.78.12.690] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The goals of early nutrition in preterm infants are to provide all the necessary vital nutrients, achieve extra-uterine growth rates similar to fetuses of the same gestational age, and support functional neurodevelopmental outcomes that are comparable to those of infants born at term. It is vital to provide nutrition that will maximally support brain growth and development, but over-feeding with accelerated growth, fat accumulation and long-term metabolic consequences should also be avoided. Because the morbidity associated with prematurity increases nutritional and energetic demands, the basic approach is of providing early intensive nutrition. Protein is the main driving force for growth and brain development. Since deficits in protein occur from the first day of extra-uterine life, sufficient quantities of parenteral amino acids should be provided from the first hours of life. With protein and carbohydrates, enough energy should also be provided, via concomitant early administration of intravenous lipid emulsions. Early initiation of enteral feeding with advancement to full enteral nutrition is associated with better maturation of the gut and better neuro-developmental outcomes. Human milk is the best food for preterm babies, although enrichment may be needed.
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Affiliation(s)
- Arieh Riskin
- Department of Neonatology, Bnai Zion Medical Center, Bruce & Ruth Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
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25
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Abstract
Infants born with low birth weights (<2500 g, LBW), accounting for about 15 % of newborns, have a high risk for postnatal growth failure and developing the metabolic syndromes such as type 2 diabetes, CVD and obesity later in life. Improper nutrition provision during critical stages, such as undernutrition during the fetal period or overnutrition during the neonatal period, has been an important mediator of these metabolic diseases. Considering the specific physiological status of LBW infants, nutritional intervention and optimisation during early life merit further attention. In this review, the physiological and metabolic defects of LBW infants were summarised from a nutritional perspective. Available strategies for nutritional interventions and optimisation of LBW infants, including patterns of nutrition supply, macronutrient proportion, supplementation of amino acids and their derivatives, fatty acids, nucleotides, vitamins, minerals as well as hormone and microbiota manipulators, were reviewed with an aim to provide new insights into the advancements of formulas and human-milk fortifiers.
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26
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Evering VHM, Andriessen P, Duijsters CEPM, Brogtrop J, Derijks LJJ. The Effect of Individualized Versus Standardized Parenteral Nutrition on Body Weight in Very Preterm Infants. J Clin Med Res 2017; 9:339-344. [PMID: 28270894 PMCID: PMC5330777 DOI: 10.14740/jocmr2893w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2017] [Indexed: 12/02/2022] Open
Abstract
Background This study was designed to evaluate whether standardizing total parenteral nutrition (TPN) is at least non-inferior to TPN with individualized composition in premature infants with a gestational age (GA) < 32 weeks. Methods In this retrospective cohort study, all preterm born in or transferred to Maxima Medical Center (MMC) within 24 hours after birth with a GA < 32 weeks were included. The individualized group (2011) was compared to the partially standardized group (2012) and completely standardized group (2014) consequently. The primary endpoint was difference in growth. Secondary endpoints included differences in electrolyte concentrations. Results A total of 299 preterm were included in this study. When comparing weight gain, the infants in the (partially) standardized group demonstrated significantly (P < 0.05) less weight loss during the first days of life and grew faster subsequently in the following days than the individualized TPN regimen. Furthermore, significant differences in abnormal serum sodium, chloride, calcium, creatinine, magnesium and triglycerides values were demonstrated. Conclusion TPN with a (partially) standardized composition revealed to be at least non-inferior to TPN with an individualized composition.
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Affiliation(s)
- Vincent H M Evering
- Department of Clinical Pharmacy, Maxima Medical Center, Veldhoven, The Netherlands
| | - Peter Andriessen
- Department of Pediatrics, Maxima Medical Center, Veldhoven, The Netherlands; Faculty of Health, Medicine and Life Science, Maastricht University, Maastricht, The Netherlands
| | | | - Jeroen Brogtrop
- Department of Clinical Pharmacy, Maxima Medical Center, Veldhoven, The Netherlands
| | - Luc J J Derijks
- Department of Clinical Pharmacy, Maxima Medical Center, Veldhoven, The Netherlands
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27
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Contreras MT, Gallardo MJ, Betancourt LR, Rada PV, Ceballos GA, Hernandez LE, Hernandez LF. Correlation between plasma levels of arginine and citrulline in preterm and full-term neonates: Therapeutical implications. J Clin Lab Anal 2017; 31. [PMID: 28169465 DOI: 10.1002/jcla.22134] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 12/13/2016] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Preterm neonates exhibit several deficiencies that endanger their lives. Understanding those disturbances will provide tools for the management of preterm neonates. The present work focuses on arginine and citrulline which has been flagged among the biochemical landmarks of prematurity. METHODS We examined blood samples of preterm newborns as compared with mature neonates to determine the levels of arginine and citrulline by capillary zone electrophoresis with laser induced fluorescence detection (CZE-LIFD). RESULTS Significantly lower levels of arginine and citrulline were found in preterm neonates than in mature neonates (P<.01). Interestingly there was a highly significant correlation between the two amino acids in mature neonates (P<.0001). Such correlation was present in preterm neonates too (P<.01). Pearson coefficient showed that 60% of the citrulline concentration depends on arginine concentration in mature neonates. Only 20% of the citrulline concentration depends on arginine concentration in preterm neonates. Although the ratio arginine/citrulline was lower in preterm neonates than in mature neonates the difference was not statistically significant. CONCLUSIONS These results suggest that less arginine is converted to citrulline to form nitric oxide in preterm than in full-term neonates. The result is discussed in terms of the immature enzymatic systems in the preterm neonate.
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Affiliation(s)
- Mike T Contreras
- School of Nutrition, Faculty of Medicine, Universidad of Los Andes, Mérida, Venezuela
| | - Maria J Gallardo
- School of Nutrition, Faculty of Medicine, Universidad of Los Andes, Mérida, Venezuela
| | - Luis R Betancourt
- Department of Morphological Sciences, Faculty of Medicine, School of Medicine, University of Los Andes, Mérida, Venezuela.,Department of Physiology, Faculty of Medicine, School of Medicine, University of Los Andes, Mérida, Venezuela
| | - Pedro V Rada
- Department of Physiology, Faculty of Medicine, School of Medicine, University of Los Andes, Mérida, Venezuela
| | - Gerardo A Ceballos
- Center of Biomedical Engineering and Telemedicine, Faculty of Engineering, University of Los Andes, Mérida, Venezuela
| | - Luis E Hernandez
- Department of Physiology, Faculty of Medicine, School of Medicine, University of Los Andes, Mérida, Venezuela
| | - Luis F Hernandez
- Department of Physiology, Faculty of Medicine, School of Medicine, University of Los Andes, Mérida, Venezuela
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Navarrete CT, Wrage LA, Carlo WA, Walsh MC, Rich W, Gantz MG, Das A, Schibler K, Newman NS, Piazza AJ, Poindexter BB, Shankaran S, Sánchez PJ, Morris BH, Frantz ID, Van Meurs KP, Cotten CM, Ehrenkranz RA, Bell EF, Watterberg KL, Higgins RD, Duara S. Growth Outcomes of Preterm Infants Exposed to Different Oxygen Saturation Target Ranges from Birth. J Pediatr 2016; 176:62-68.e4. [PMID: 27344218 PMCID: PMC5327617 DOI: 10.1016/j.jpeds.2016.05.070] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 03/31/2016] [Accepted: 05/20/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To test whether infants randomized to a lower oxygen saturation (peripheral capillary oxygen saturation [SpO2]) target range while on supplemental oxygen from birth will have better growth velocity from birth to 36 weeks postmenstrual age (PMA) and less growth failure at 36 weeks PMA and 18-22 months corrected age. STUDY DESIGN We evaluated a subgroup of 810 preterm infants from the Surfactant, Positive Pressure, and Oxygenation Randomized Trial, randomized at birth to lower (85%-89%, n = 402, PMA 26 ± 1 weeks, birth weight 839 ± 186 g) or higher (91%-95%, n = 408, PMA 26 ± 1 weeks, birth weight 840 ± 191 g) SpO2 target ranges. Anthropometric measures were obtained at birth, postnatal days 7, 14, 21, and 28; then at 32 and 36 weeks PMA; and 18-22 months corrected age. Growth velocities were estimated with the exponential method and analyzed with linear mixed models. Poor growth outcome, defined as weight <10th percentile at 36 weeks PMA and 18-22 months corrected age, was compared across the 2 treatment groups by the use of robust Poisson regression. RESULTS Growth outcomes including growth at 36 weeks PMA and 18-22 months corrected age, as well as growth velocity were similar in the lower and higher SpO2 target groups. CONCLUSION Targeting different oxygen saturation ranges between 85% and 95% from birth did not impact growth velocity or reduce growth failure in preterm infants.
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Affiliation(s)
| | - Lisa A. Wrage
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, NC
| | - Waldemar A. Carlo
- Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL
| | - Michele C. Walsh
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH
| | - Wade Rich
- Division of Neonatology, University of California San Diego, San Diego, CA
| | - Marie G. Gantz
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, NC
| | - Abhik Das
- Social, Statistical and Environmental Sciences Unit, RTI International, Rockville, MD
| | - Kurt Schibler
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, OH
| | - Nancy S. Newman
- Division of Neonatology, University of California San Diego, San Diego, CA
| | - Anthony J. Piazza
- Emory University School of Medicine, Department of Pediatrics, and Children’s Healthcare of Atlanta, Atlanta, GA
| | - Brenda B. Poindexter
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | | | - Pablo J. Sánchez
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Brenda H. Morris
- Department of Pediatrics, University of Texas Medical School at Houston, Houston, TX
| | - Ivan D. Frantz
- Department of Pediatrics, Division of Newborn Medicine, Floating Hospital for Children, Tufts Medical Center, Boston, MA
| | - Krisa P. Van Meurs
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, CA
| | | | | | - Edward F. Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA
| | | | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - Shahnaz Duara
- University of Miami Miller School of Medicine, Miami, FL
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Abdallah EA, Said RN, Mosallam DS, Moawad EM, Kamal NM, Fathallah MGD. Serial serum alkaline phosphatase as an early biomarker for osteopenia of prematurity. Medicine (Baltimore) 2016; 95:e4837. [PMID: 27631238 PMCID: PMC5402581 DOI: 10.1097/md.0000000000004837] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 08/17/2016] [Accepted: 08/19/2016] [Indexed: 02/03/2023] Open
Abstract
Metabolic bone disease of prematurity is a condition characterized by reduction in bone mineral content (osteopenia). It is a problem faced by very low birth weight (VLBW) infants because of lack of fetal mineralization during the last trimester. Our aim was to assess serum alkaline phosphatase (ALP) level as an early biomarker for osteopenia in premature infants and to estimate an optimal cutoff value of serum ALP at which osteopenia is detected radiologically in premature newborns.This prospective study was conducted on a cohort of 120 newborn infants of both sex of ≤34 weeks' gestational age and <1500 g birth weight. Two blood samples, from each infant on at least 2 consecutive weeks, were reported for calcium, phosphorus, and ALP. Evidence of osteopenia was evaluated radiologically by performing wrist/knee x-ray.Sixteen infants (13.3%) had evidence of osteopenia in x-ray, whereas 104 infants (86.7%) were nonosteopenic and all the osteopenic infants were <1000-g birth weight. Birth weight and gestational age were significantly inversely related to serum ALP levels. Both samples showed statistically significantly higher mean ALP level in osteopenic than nonosteopenics (P < 0.001, and P < 0.001 respectively). There was no constant value of serum ALP related to radiologic evidence of osteopenia. However, the optimal cutoff value of serum ALP at which osteopenia is detected is 500 IU/L with 100% sensitivity and 80.77% specificity.High levels of ALP can be considered a reliable biomarker to predict the status of bone mineralization and the need for radiological evaluation in premature infants particularly those <1000-g birth weight and <32 weeks' gestation.
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Affiliation(s)
- Enas A.A. Abdallah
- Pediatric Department, Faculty of Medicine, Cairo University, Cairo, Egypt
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30
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Does High Protein Intake During First Week of Life Improve Growth and Neurodevelopmental Outcome at 18 months Corrected Age in Extremely Preterm Infants? Indian J Pediatr 2016; 83:915-21. [PMID: 26608051 DOI: 10.1007/s12098-015-1918-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 09/30/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To examine whether high protein intake during the first week of life alters the growth and neurodevelopmental outcomes at 18 mo corrected age (CA) in preterm infants born < 29 wk. METHODS This was a retrospective cohort study of preterm infants (<29 wk) before and after introduction of nutritional policy targeting higher protein intake during the first week of life. The authors compared the growth and neurodevelopmental outcomes at 18 mo CA between infants born before (epoch 1) and after (epoch 2) the introduction of nutrition policy. RESULTS Of 171 eligible infants who completed follow-up at 18 mo CA, 87 (51 %) were in post intervention group (epoch 2). The mean (± SD) gestational age (26.3 ± 1.49 wk vs. 26.2 ± 1.48 wk) and birth weight (947 ± 220 g vs. 924 ± 225 g) were similar between the two groups. At 18 mo CA, there were no significant differences in the growth and neurodevelopmental impairment rates between the two groups. Logistic regression analysis revealed that high protein intake (>3.5 g/kg/d) was not associated with improved neurodevelopmental outcome (OR 1.49, 95 % CI 0.52-4.26). CONCLUSIONS High protein intake during the first week of age was not associated with better growth or neurodevelopmental outcome at 18 mo CA in preterm infants.
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Li Z, Valentine CJ, Wang D, Wang L, Dong M. Comparison of enteral feeding of preterm infants between two hospitals in China and United States. J Matern Fetal Neonatal Med 2016; 30:121-125. [PMID: 27345030 DOI: 10.3109/14767058.2016.1163681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AIM To compare the details of preterm infants enteral feeding between the two hospitals in China and in the United States, and to analyze the reason of the differences. METHODS A retrospective cohort study was conducted. Infants < 32 weeks were enrolled from Cincinnati University Hospital (CUH) during January 2011 to January 2012 and Peking Union Medical College Hospital (PUMCH) during January 2011 to May 2012. Basic data and enteral feeding data of the two groups were compared. RESULTS Eighty-two infants in CUH group and 74 infants in PUMCH group were enrolled, infants in CUH group were much smaller than PUMCH group (gestational age (29.1 ± 2.0) versus (30.6 ± 1.3) weeks, p = 0.000, birth weight (1204 ± 328) versus (1406 ± 320) g, p = 0.000). Significantly more infants in CUH group received human milk as the first enteral feeding (78/82 versus 7/74, p = 0.000). Human milk feeding rate in first 28 days in CUH group was much higher (77/82 versus 7/74, p = 0.000). The initial milk volume, and the milk volume on the 7th, 14th, 21st and 27th day of CUH group were significant larger [(15.9 versus 9.3 ml/kg·d, p = 0.000), (79.8 versus 35.2 ml/kg·d, p = 0.000), (133.2 versus 76.4 ml/kg·d, p = 0.000), (140.6 versus 108.6 ml/kg·d, p = 0.000), (142.2 versus 121.5 ml/kg·d, p = 0.002)]. CUH group achieved full enteral feeding sooner (12.0 versus 22.4 d, p = 0.000). CONCLUSION Preterm infants achieved full enteral feeding sooner at CUH compared to PUMCH. Human milk feeding may improve enteral feeding tolerance. We need more aggressive enteral feeding proposal in PUMCH.
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Affiliation(s)
- Zhenghong Li
- a Department of Pediatrics , Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences , Beijing , China and
| | - Christina J Valentine
- b Section of Neonatology Perinatal & Pulmonary Biology, Cincinnati Children's Hospital Medical Center, The University of Cincinnati , Cincinnati , OH , USA
| | - Danhua Wang
- a Department of Pediatrics , Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences , Beijing , China and
| | - Lin Wang
- a Department of Pediatrics , Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences , Beijing , China and
| | - Mei Dong
- a Department of Pediatrics , Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences , Beijing , China and
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Risk factors of late-onset neonatal sepsis in Taiwan: A matched case-control study. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2016; 49:430-5. [DOI: 10.1016/j.jmii.2013.10.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Revised: 07/11/2013] [Accepted: 08/05/2013] [Indexed: 11/23/2022]
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Lima AMD, Goulart AL, Bortoluzzo AB, Kopelman BI. Nutritional practices and postnatal growth restriction in preterm newborns. Rev Assoc Med Bras (1992) 2016; 61:500-6. [PMID: 26841159 DOI: 10.1590/1806-9282.61.06.500] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 08/24/2014] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE to assess the nutritional practices in neonatal intensive care units (NICU) associated with growth retardation in premature (preterm) infants. METHODS retrospective study of preterm infants weighing between 500 and 1,499 g admitted to NICU. Evolution of growth and parenteral (PN) and enteral (EN) nutrition practices were analyzed. RESULTS among 184 preterm infants divided into G1 (500 to 990 g; n=63) and G2 (1000 to 1499 g; n=121), 169 received PN (G1=63, G2=106). Compared with the recommendations, PN was started late, its progress was slow and the maximum glucose, amino acid, lipid and energy supplies were low in both groups. The initial supply of amino acid and lipid and initial and maximum glucose and energy were lower in G1. The onset of EN was early (1-2 days), the time to reach exclusive EN was appropriate (11-15 days) and the use of human milk was possible in a reasonable amount of time (7-13 days). The multivariate analysis showed that respiratory distress syndrome and obtaining a supply of 120 kcal/kg/day too late increased the chance of weight loss greater than 10%. Sepsis, maximum energy supply for PN <60 kcal/kg/day and obtaining a supply of 120 kcal/kg/day too late increased the chance of regaining birth weight after 14 days, while small for gestational age (SGA) at birth reduced this chance. SGA at birth, sepsis and achieving exclusive enteral nutrition after 14 days increased the chance of being SGA at post-conceptual age of term. CONCLUSION improving nutritional practices in the NICU can reduce the growth deficit in premature infants of very low birth weight.
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Brener Dik PH, Galletti MF, Fernández Jonusas SA, Alonso G, Mariani GL, Fustiñana CA. Early hypophosphatemia in preterm infants receiving aggressive parenteral nutrition. J Perinatol 2015; 35:712-5. [PMID: 26067471 DOI: 10.1038/jp.2015.54] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Revised: 04/06/2015] [Accepted: 04/16/2015] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To report the prevalence of hypophosphatemia during the first week of life in preterm infants receiving aggressive parenteral nutrition and to analyze population variables associated with severe hypophosphatemia. STUDY DESIGN A retrospective cohort of 61 neonates below 1250 g birth weight consecutively born at Hospital Italiano de Buenos Aires exposed to high caloric and protein intake from the first day of birth. Primary outcome was hypophosphatemia (phosphate <4 mg dl(-1)). A one-sample mean comparison test was used to compare our sample with a hypothesized population mean. RESULTS The prevalence of hypophosphatemia was 91% (95% confidence interval (CI) 82 to 97%). The mean phosphatemia value was 2.52 mg dl(-1) (95% CI 2.18 to 2.86), significantly different from the hypothesized population mean (P<0.001). Patients with severe hypophosphatemia (<2 mg dl(-1)) were smaller. They presented with sepsis more frequently and received more vasoactive drugs and mechanical ventilation. CONCLUSION The prevalence of hypophosphatemia in this group of preterm infants is high. The potential association with adverse clinical outcomes deserves further research.
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Affiliation(s)
- P H Brener Dik
- Division of Neonatology, Department of Pediatrics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - M F Galletti
- Division of Neonatology, Department of Pediatrics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - S A Fernández Jonusas
- Division of Neonatology, Department of Pediatrics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - G Alonso
- Department of Pediatrics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - G L Mariani
- Division of Neonatology, Department of Pediatrics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - C A Fustiñana
- Division of Neonatology, Department of Pediatrics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Rice MS, Valentine CJ. Neonatal Body Composition: Measuring Lean Mass as a Tool to Guide Nutrition Management in the Neonate. Nutr Clin Pract 2015; 30:625-32. [PMID: 25908606 DOI: 10.1177/0884533615578917] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Neonatal nutrition adequacy is often determined by infant weight gain. The aim of this review is to summarize what is currently known about neonatal body composition and the use of body composition as a measure for adequate neonatal nutrition. Unlike traditional anthropometric measures of height and weight, body composition measurements account for fat vs nonfat mass gains. This provides a more accurate picture of neonatal composition of weight gain. Providing adequate neonatal nutrition in the form of quantity and composition can be a challenge, especially when considering the delicate balance of providing adequate nutrition to preterm infants for catch-up growth. Monitoring weight gain as fat mass and nonfat mass while documenting dietary intake of fat, protein, and carbohydrate in formulas may help provide the medical community the tools to provide optimal nutrition for catch-up growth and for improved neurodevelopmental outcomes. Tracking body composition in term and preterm infants may also provide critical future information concerning the nutritional state of infants who go on to develop future disease such as obesity, hypertension, and hyperlipidemia as adolescents or adults.
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Affiliation(s)
- Melissa S Rice
- Division of Neonatology, Perinatal and Pulmonary Biology, Center for Interdisciplinary Research in Human Milk and Lactation, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio Parkview Regional Medical Center, Fort Wayne, Indiana. Dr Valentine is now employed by Mead Johnson Nutrition, Evansville, Indiana
| | - Christina J Valentine
- Division of Neonatology, Perinatal and Pulmonary Biology, Center for Interdisciplinary Research in Human Milk and Lactation, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Baudouin A, Diouf E, Tall ML, Duval S, Provôt S, Picaud JC, Claris O, Pivot C, Pirot F. Avantages et spécificités des préparations hospitalières de nutrition parentérale en néonatalogie. ANNALES PHARMACEUTIQUES FRANÇAISES 2015; 73:150-9. [DOI: 10.1016/j.pharma.2014.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 06/06/2014] [Accepted: 06/12/2014] [Indexed: 10/25/2022]
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Velasco Benítez CA, Farfán Cruz G. Aumento de peso después de soporte nutricional en una unidad de cuidado intensivo neonatal. REVISTA DE LA FACULTAD DE MEDICINA 2015. [DOI: 10.15446/revfacmed.v62n3sup.40899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Liu MY, Chen YY, Hu SH, Chen YK, Chang SJ. The Influence of Aggressive Parenteral Nutrition to Preterm and Very Low Birth Weight Infants. Glob Pediatr Health 2015; 2:2333794X14567192. [PMID: 27335933 PMCID: PMC4784588 DOI: 10.1177/2333794x14567192] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background. To achieve the weight gain of preterm infants who are appropriate for gestational age without adverse effect, there should be no interruption in delivery of nutrients from time of birth. Methods. Twenty-eight very low birth weight infants were eligible for the study. Those administered conventional nutrition (amino acids 2 g/kg/day started on third day of life) were classified as the conventional support (CVS) group, and those administered aggressive early nutrition (amino acid 2 g/kg/day started on first day of life) were classified as the aggressive support (AGS) group. Results. The days babies took to reach the weight of 2000 g in the AGS group was significantly shorter than for babies in the CVS group, and babies in the AGS group showed better tolerance to enteral nutrition and had shortened neonatal intensive care unit days. Conclusion. The results demonstrated that aggressive early nutrition showed better tolerance to enteral nutrition, higher total calories, and shortened the stay in the neonatal intensive care unit.
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Affiliation(s)
| | | | - Shu-Hui Hu
- Kaohsiung Medical University, Kaohsiung, Taiwan
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Shim SY, Ahn HM, Cho SJ, Park EA. Early aggressive nutrition enhances language development in very low-birthweight infants. Pediatr Int 2014; 56:845-850. [PMID: 24750193 DOI: 10.1111/ped.12361] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Revised: 03/06/2014] [Accepted: 04/11/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Inadequate nutrition in very-low-birthweight (VLBW) infants is known to be associated with growth failure and poor neurological outcomes. We aimed to investigate the association of early aggressive protein and energy intakes with weight gain and 18-month neurodevelopmental outcomes in VLBW infants. METHODS A total of 90 infants among 129 infants who survived to discharge were included and divided into two groups (early aggressive nutrition [n = 52] vs conventional nutrition [n = 38]). Clinical findings were compared between the two groups and daily protein and energy intakes were collected for the first 4 weeks of life. Multiple regression analyses tested the association between weekly protein or energy intakes and the result of each category of the Denver Developmental Screening Test II at 18 months' corrected age or weight gain. RESULTS The early aggressive nutrition group had higher rates of normal language development and lower rates of growth failure (<10th percentile) at both 40 weeks' and 18 months' corrected age compared to the conventional nutrition group. After controlling for the confounding variables, higher first week protein and energy intakes each independently contributed to normal language development (odds ratio [95% confidence interval]; 9.4 [1.8-49.6] per 1 g/kg of protein increase and 1.7 [1.1-2.8] per 10 kcal/kg of energy increase). Higher first-week protein intake was associated with a higher weight at 40 weeks' corrected age (r = 0.41, P = 0.005). CONCLUSIONS This study demonstrates the importance of the protein and energy intakes in VLBW infants in the first week of life not only for growth but also for better language development.
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Affiliation(s)
- So-Yeon Shim
- Department of Pediatrics, Ewha Womans University School of Medicine, Seoul, Korea
| | - Hye Mi Ahn
- Department of Pediatrics, Ewha Womans University School of Medicine, Seoul, Korea
| | - Su Jin Cho
- Department of Pediatrics, Ewha Womans University School of Medicine, Seoul, Korea
| | - Eun Ae Park
- Department of Pediatrics, Ewha Womans University School of Medicine, Seoul, Korea
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Isemann B, Mueller EW, Narendran V, Akinbi H. Impact of Early Sodium Supplementation on Hyponatremia and Growth in Premature Infants: A Randomized Controlled Trial. JPEN J Parenter Enteral Nutr 2014; 40:342-9. [PMID: 25406227 DOI: 10.1177/0148607114558303] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 10/07/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND We tested the hypothesis that sodium supplementation in early preterm infants prevents late-onset hyponatremia and improves growth without increasing common morbidities during birth hospitalization. MATERIALS AND METHODS This was a randomized, masked controlled trial of 4 mEq/kg/d of sodium (intervention) versus sterile water (placebo) from days-of-life 7 to 35 in infants born at <32 weeks corrected gestational age. The primary outcome was weight gain in the first 6 weeks of life. Secondary outcomes included weekly serum sodium concentrations, growth in body length and head circumference, and complications of prematurity during birth hospitalization. RESULTS Fifty-three infants with an average corrected gestational age of 28.5 ± 2.4 weeks were randomized. Infants receiving the intervention had fewer (P = .012) reports of serum sodium concentrations <135 mmol/L and greater velocity of weight gain during the study period, mean (SD) 26.9 (3.1) vs 22.9 (4.7) g/kg/day, P = .012. At 6 weeks of age, infants <28 weeks' gestation who received sodium supplementation had greater percentage weight change from birth, mean (SD) 193% (22%) vs 173% (10%), P = .041, and maintained fetal reference birth percentile for body weight more often (P = .002) compared with infants receiving placebo. Growth in length and head circumference was not significantly different between study arms. No increase in common prematurity-related morbidities was detected in infants who received supplemental sodium chloride. CONCLUSION Sodium supplementation of enteral feedings in very premature infants averts hyponatremia and enhances weight gain.
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Affiliation(s)
| | - Eric W Mueller
- University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Vivek Narendran
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Henry Akinbi
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Gidrewicz DA, Fenton TR. A systematic review and meta-analysis of the nutrient content of preterm and term breast milk. BMC Pediatr 2014; 14:216. [PMID: 25174435 PMCID: PMC4236651 DOI: 10.1186/1471-2431-14-216] [Citation(s) in RCA: 363] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 08/22/2014] [Indexed: 12/22/2022] Open
Abstract
Background Breast milk nutrient content varies with prematurity and postnatal age. Our aims were to conduct a meta-analysis of preterm and term breast milk nutrient content (energy, protein, lactose, oligosaccharides, fat, calcium, and phosphorus); and to assess the influence of gestational and postnatal age. Additionally we assessed for differences by laboratory methods for: energy (measured vs. calculated estimates) and protein (true protein measurement vs. the total nitrogen estimates). Methods Systematic review results were summarized graphically to illustrate the changes in composition over time for term and preterm milk. Since breast milk fat content varies within feeds and diurnally, to obtain accurate estimates we limited the meta-analyses for fat and energy to 24-hour breast milk collections. Results Forty-one studies met the inclusion criteria: 26 (843 mothers) preterm studies and 30 (2299 mothers) term studies of breast milk composition. Preterm milk was higher in true protein than term milk, with differences up to 35% (0.7 g/dL) in colostrum, however, after postnatal day 3, most of the differences in true protein between preterm and term milk were within 0.2 g/dL, and the week 10–12 estimates suggested that term milk may be the same as preterm milk by that age. Colostrum was higher than mature milk for protein, and lower than mature milk for energy, fat and lactose for both preterm and term milk. Breast milk composition was relatively stable between 2 and 12 weeks. With milk maturation, there was a narrowing of the protein variance. Energy estimates differed whether measured or calculated, from −9 to 13%; true protein measurement vs. the total nitrogen estimates differed by 1 to 37%. Conclusions Although breast milk is highly variable between individuals, postnatal age and gestational stage (preterm versus term) were found to be important predictors of breast milk content. Energy content of breast milk calculated from the macronutrients provides poor estimates of measured energy, and protein estimated from the nitrogen over-estimates the protein milk content. When breast milk energy, macronutrient and mineral content cannot be directly measured the average values from these meta-analyses may provide useful estimates of mother’s milk energy and nutrient content.
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Affiliation(s)
- Dominica A Gidrewicz
- Department of Pediatrics, University of Calgary, 2888 Shaganappi Trail NW, Calgary, AB T3B 6A8, Canada.
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Abstract
Approximately 10% of all babies worldwide are born preterm, and preterm birth is the leading cause of perinatal mortality in developed countries. Although preterm birth is associated with adverse short- and long-term health outcomes, it is not yet clear whether this relationship is causal. Rather, there is evidence that reduced foetal growth, preterm birth and the long-term health effects of both of these may all arise from a suboptimal intrauterine environment. Further, most infants born preterm also experience suboptimal postnatal growth, with potential adverse effects on long-term health and development. A number of interventions are used widely in the neonatal period to optimise postnatal growth and development. These commonly include supplementation with macronutrients and/or micronutrients, all of which have potential short-term risks and benefits for the preterm infant, whereas the long-term health consequences are largely unknown. Importantly, more rapid postnatal growth trajectory (and the interventions required to achieve this) may result in improved neurological outcomes at the expense of increased cardiovascular risk in later life.
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Abstract
OBJECTIVE The aim of the present study was to determine whether an increased supply of energy, protein, essential fatty acids, and vitamin A reduces postnatal growth failure in very-low-birth-weight infants. METHODS Fifty infants with birth weight <1500 g were randomized to an intervention (n = 24) or a control (n = 26) feeding protocol within 24 hours after birth. Forty-four infants were included in the final analysis. This study was discontinued because of an increased occurrence of septicemia in the intervention group. RESULTS The intervention group had a lower mean birth weight (P = 0.03) and a higher proportion of infants small-for-gestational age (P = 0.04) than the control group. Other baseline characteristics were similar. The median (interquartile range) energy and protein supplies during the first 4 weeks of life were higher in the intervention group: 139 (128-145) versus 126 (121-128) kcal · kg · day (P < 0.001) and 4.0 (3.9-4.2) versus 3.2 (3.1-3.3) g · kg · day (P < 0.001). The infants in the intervention group regained birth weight faster (P = 0.001) and maintained their z scores for weight and head circumference from birth to 36 weeks' postmenstrual age (both P < 0.001). The median (interquartile range) growth velocity was 17.4 (16.3-18.6) g · kg · day in the intervention group and 13.8 (13.2-15.5) g · kg · day in the control group (P < 0.001). In line with the improved growth in the intervention group, the proportion of growth-restricted infants was 11 of 23 both at birth and at 36 weeks' postmenstrual age, whereas this proportion increased among the controls from 4 of 21 to 13 of 21 (P = 0.04). CONCLUSIONS Enhanced supply of energy, protein, essential fatty acids, and vitamin A caused postnatal growth along the birth percentiles for both weight and head circumference.
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Enteral zinc supplementation and growth in extremely-low-birth-weight infants with chronic lung disease. J Pediatr Gastroenterol Nutr 2014; 58:183-7. [PMID: 24121149 PMCID: PMC4125018 DOI: 10.1097/mpg.0000000000000145] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Zinc deficiency causes growth deficits. Extremely-low-birth-weight (ELBW) infants with chronic lung disease (CLD), also known as bronchopulmonary dysplasia, experience growth failure and are at risk for zinc deficiency. We hypothesized that enteral zinc supplementation would increase weight gain and linear growth. METHODS A cohort of infants was examined retrospectively at a single center between January 2008 and December 2011. CLD was defined as the need for oxygen at 36 weeks postmenstrual age. Zinc supplementation was started in infants who had poor weight gain. Infants' weight gain and linear growth were compared before and after zinc supplementation using the paired t test. RESULTS A total of 52 ELBW infants with CLD met entry criteria. Mean birth weight was 682 ± 183 g, and gestational age was 25.3 ± 2 weeks. Zinc supplementation started at postmenstrual age 33 ± 2 weeks. Most infants received fortified human milk. Weight gain increased from 10.9 before supplementation to 19.9 g · kg(-1) · day(-1) after supplementation (P < 0.0001). Linear growth increased from 0.7 to 1.1 cm/week (P = 0.001). CONCLUSIONS Zinc supplementation improved growth in ELBW infants with CLD receiving human milk. Further investigation is warranted to reevaluate zinc requirements, markers, and balance.
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Johnson PJ. Review of macronutrients in parenteral nutrition for neonatal intensive care population. Neonatal Netw 2014; 33:29-34. [PMID: 24413034 DOI: 10.1891/0730-0832.33.1.29] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Parenteral nutrition (PN) has become essential in the management of sick and growing newborn populations in the NICU. In the past few decades, PN has become fundamental in the nutritional management of the very low birth weight infant (<1,500 g).1 Although the components in PN are commonly determined and ordered by the physician or neonatal nurse practitioner provider, the NICU nurse is responsible for confirming the components in the daily PN prior to infusion and is responsible for maintaining the infusion of PN. Nurses should understand the nutritional components of PN as well as the indications, side effects, and infusion limitations of each component. The purpose of this article is to review the macronutrients in PN, including carbohydrates, protein, and fat. A subsequent article will review the micronutrients in PN, including electrolytes, minerals, and vitamins.
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Thoene M, Hanson C, Lyden E, Dugick L, Ruybal L, Anderson-Berry A. Comparison of the effect of two human milk fortifiers on clinical outcomes in premature infants. Nutrients 2014; 6:261-75. [PMID: 24394538 PMCID: PMC3916860 DOI: 10.3390/nu6010261] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Revised: 12/17/2013] [Accepted: 12/20/2013] [Indexed: 01/01/2023] Open
Abstract
The use of human milk fortifiers (HMF) helps to meet the high nutritional requirements of the human milk-fed premature infant. Previously available powdered products have not met the protein requirements of the preterm infant population and many neonatologists add powder protein modulars to help meet protein needs. The use of powdered products is discouraged in neonatal intensive care units (NICU) due to concern for invasive infection. The use of a commercially available acidified liquid product with higher protein content was implemented to address these two concerns. During the course of this implementation, poor growth and clinically significant acidosis of infants on Acidified Liquid HMF (ALHMF) was observed. The purpose of this study was to quantify those observations by comparing infant outcomes between groups receiving the ALHMF vs. infants receiving powdered HMF (PHMF). A retrospective chart review compared outcomes of human milk-fed premature infants<2000 g receiving the ALHMF (n=23) and the PHMF (n=46). Infant growth, enteral feeding tolerance and provision, and incidence of necrotizing enterocolitis (NEC), metabolic acidosis, and diaper dermatitis were compared between the two groups. No infants were excluded from this study based on acuity. Use of ALHMF resulted in a higher incidence of metabolic acidosis (p=0.002). Growth while on HMF as measured in both g/kg/day (10.59 vs. 15.37, p<0.0001) and in g/day (23.66 vs. 31.27, p=0.0001) was slower in the ALHMF group, on increased mean cal/kg/day (128.7 vs. 117.3, p=0.13) with nearly twice as many infants on the ALHMF requiring increased fortification of enteral feedings beyond 24 cal/ounce to promote adequate growth (48% vs. 26%, p=0.10). Although we were not powered to study NEC as a primary outcome, NEC was significantly increased in the ALHMF group. (13% vs. 0%, p=0.03). Use of a LHMF in an unrestricted NICU population resulted in an increase in clinical complications within a high-acuity NICU, including metabolic acidosis and poor growth. Although further research is needed to assess outcomes among infants with a variety of clinical acuities, gestational ages, and weights to confirm these findings, based on this experience, caution is urged to avoid potential risks.
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Affiliation(s)
- Melissa Thoene
- Newborn Intensive Care Unit, Nebraska Medical Center, Omaha, NE 68198, USA.
| | - Corrine Hanson
- Newborn Intensive Care Unit, Nebraska Medical Center, Omaha, NE 68198, USA.
| | - Elizabeth Lyden
- Newborn Intensive Care Unit, Nebraska Medical Center, Omaha, NE 68198, USA.
| | - Laura Dugick
- Newborn Intensive Care Unit, Nebraska Medical Center, Omaha, NE 68198, USA.
| | - Leslie Ruybal
- Newborn Intensive Care Unit, Nebraska Medical Center, Omaha, NE 68198, USA.
| | - Ann Anderson-Berry
- Newborn Intensive Care Unit, Nebraska Medical Center, Omaha, NE 68198, USA.
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Abstract
Nutrition of preterm infants should result in growth similar to that of normally growing fetuses of the same gestational age. Unfortunately, most preterm infants are not fed enough to achieve this objective; as a result they are growth restricted by term gestation. Recent studies have demonstrated that early and enhanced "aggressive" nutrition of preterm infants can reduce postnatal growth failure and improve longer-term outcomes, particularly for the brain and its cognitive functions. When preterm infants are fed more aggressively (earlier onset of intravenous and enteral feeding, earlier achievement of full enteral feeding) cumulative energy and protein deficits are reduced and they consistently regain birth weight sooner, the incidence of necrotizing enterocolitis and late-onset sepsis is unchanged or reduced, and they achieve discharge criteria and go home sooner, with overall shorter hospital stays, and have improved anthropometrics by term gestation. More research is needed, however, to determine optimum feeding of preterm infants, particularly during periods of illness and physiological instability.
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Affiliation(s)
- William W. Hay
- Department of Pediatrics, Perinatal Research Center, University of Colorado School of Medicine, Anschutz Medical Campus F441, 13243 East 23rd Avenue, Aurora, CO 80045, USA
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Optimizing protein intake in premature infants: a neonatal quality improvement project. Adv Neonatal Care 2013; 13:E1-8. [PMID: 24300966 DOI: 10.1097/anc.0b013e3182a0a178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This article examines a quality-improvement project to reduce clinical practice variation and measure growth outcomes by standardizing the process for the provision of protein intake for premature infants weighing 1250 g or less. Eighteen infants with a birth weight of 1250 g or less and gestational age of 32 weeks or less born between June and October 2010 were compared with 15 historical controls of the same birth weight and gestation born between January and May 2010 using a prospective cohort design. The prospective group followed a newly implemented standardized protein nutritional guideline. Independent t-tests and repeated measures of analyses of variance (between- and within-subjects) were performed on the difference between the intended and actual protein intakes between the 2 groups. A multivariate analysis of variance computed the difference between the birth and discharge gains. The prospective group showed statistically significant differences between the amount of intended and actual protein intakes (P = .023) when compared with historical controls. Growth outcomes were not significantly different (P = .67) between the 2 groups. Length of stay was not statistically significantly shorter (P = .06) in the prospective group. Reduction in clinical practice variation was associated with the implementation of a protein nutritional guideline. There was no statistical support for an improvement in the growth outcomes or reduction in length of stay.
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Burattini I, Bellagamba MP, Spagnoli C, D'Ascenzo R, Mazzoni N, Peretti A, Cogo PE, Carnielli VP. Targeting 2.5 versus 4 g/kg/day of amino acids for extremely low birth weight infants: a randomized clinical trial. J Pediatr 2013; 163:1278-82.e1. [PMID: 23941670 DOI: 10.1016/j.jpeds.2013.06.075] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Revised: 05/03/2013] [Accepted: 06/27/2013] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare the effect of 2.5 vs 4 g/kg/d of amino acid (AA) in parenteral nutrition of extremely low birth weight infants on metabolic tolerance, short-term growth, and neurodevelopment. STUDY DESIGN One hundred thirty-one infants with birth weight between 500 and 1249 g were randomized to 2.5 (standard AA [SAA] group) or 4 (high AA [HAA] group) g/kg/d AA intake, with equal nonprotein energy. The primary outcome was body size at 36 weeks. RESULTS One hundred thirty-one patients were randomized and 114 analyzed (58 SAA group and 56 HAA group). Study groups had similar demographics and clinical characteristics. Elevated blood urea (BU >70 mg/dL = BU nitrogen >32.6 mg/dL) occurred in 24% vs 59% (P = .000) and hyperglycemia (>175 mg/dL) in 34% vs 11% (P = .003) of the SAA and HAA patients, respectively. Body weight, length, and head circumference at 36 weeks and 2 years were similar between groups. Bayley Scales of Infant and Toddler Development, Third Edition score was 94 ± 13 in the SAA group and 97 ± 15 in the HAA group (P = .35). CONCLUSIONS The HAA group had higher BU levels and better glucose control. An extra 8 g/kg of AA over the first 10 days of life did not improve growth and neurodevelopment.
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Affiliation(s)
- Ilaria Burattini
- Division of Neonatology, Department of Mother and Child Health, Ospedale Salesi-Azienda Ospedaliero Universitaria Ospedali Riuniti, Ancona, Italy.
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Reduction in newborn screening metabolic false-positive results following a new collection protocol. Genet Med 2013; 16:477-83. [DOI: 10.1038/gim.2013.171] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 09/25/2013] [Indexed: 11/08/2022] Open
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