Randomized diet in the neonatal period and growth performance until 7.5-8 y of age in preterm children

Donor human milk for preventing necrotising enterocolitis in very preterm or very low-birthweight infants

BACKGROUND

When sufficient maternal milk is not available, donor human milk or formula are the alternative forms of enteral nutrition for very preterm or very low-birthweight (VLBW) infants. Donor human milk may retain the non-nutritive benefits of maternal milk and has been proposed as a strategy to reduce the risk of necrotising enterocolitis (NEC) and associated mortality and morbidity in very preterm or VLBW infants.

OBJECTIVES

To assess the effectiveness of donor human milk compared with formula for preventing NEC and associated morbidity and mortality in very preterm or VLBW infants when sufficient maternal milk is not available.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Maternity and Infant Care (MIC) database, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL), from the earliest records to February 2024. We searched clinical trials registries and examined the reference lists of included studies.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing feeding with donor human milk versus formula in very preterm (< 32 weeks' gestation) or VLBW (< 1500 g) infants.

DATA COLLECTION AND ANALYSIS

Two review authors evaluated the risk of bias in the trials, extracted data, and synthesised effect estimates using risk ratio, risk difference, and mean difference, with associated 95% confidence intervals. The primary outcomes were NEC, late-onset invasive infection, and all-cause mortality before hospital discharge. The secondary outcomes were growth parameters and neurodevelopment. We used the GRADE approach to assess the certainty of the evidence for our primary outcomes.

MAIN RESULTS

Twelve trials with a total of 2296 infants fulfilled the inclusion criteria. Most trials were small (average sample size was 191 infants). All trials were performed in neonatal units in Europe or North America. Five trials were conducted more than 40 years ago; the remaining seven trials were conducted in the year 2000 or later. Some trials had methodological weaknesses, including concerns regarding masking of investigators and selective reporting. Meta-analysis showed that donor human milk reduces the risk of NEC (risk ratio (RR) 0.53, 95% confidence interval (CI) 0.37 to 0.76; I² = 4%; risk difference (RD) -0.03, 95% CI -0.05 to -0.01; 11 trials, 2261 infants; high certainty evidence). Donor human milk probably has little or no effect on late-onset invasive infection (RR 1.12, 0.95 to 1.31; I² = 27%; RD 0.03, 95% CI -0.01 to -0.07; 7 trials, 1611 infants; moderate certainty evidence) or all-cause mortality (RR 1.00, 95% CI 0.76 to 1.31; I² = 0%; RD -0.00, 95% CI -0.02 to 0.02; 9 trials, 2116 infants; moderate certainty evidence).

AUTHORS' CONCLUSIONS

The evidence shows that donor human milk reduces the risk of NEC by about half in very preterm or VLBW infants. There is probably little or no effect on late-onset invasive infection or all-cause mortality before hospital discharge.

High protein intake on later outcomes in preterm children: a systematic review and meta-analysis

BACKGROUND

Appropriate protein intake is crucial for growth and development in children born preterm. We assessed the effects of high (HP) versus low protein (LP) intake on neurodevelopment, growth, and biochemical anomalies in these children.

METHODS

Randomised and quasi-randomised trials providing protein to children born preterm (<37 completed weeks of gestation) were searched following PRISMA guideline in three databases and four registers (PROSPERO registration CRD42022325659). Random-effects model was used for assessing the effects of HP (≥3.5 g/kg/d) vs. LP (<3.5 g/kg/d).

RESULTS

Data from forty-four studies (n = 5338) showed HP might slightly reduce the chance of survival without neurodisability at ≥12 months (four studies, 1109 children, relative risk [RR] 0.95 [95% CI 0.90, 1.01]; P = 0.13; low certainty evidence) and might increase risk of cognitive impairment at toddler age (two studies; 436 children; RR 1.36 [0.89, 2.09]; P = 0.16; low certainty evidence). At discharge or 36 weeks, HP intake might result in higher weight and greater head circumference z-scores. HP intake probably increased the risk of hypophosphatemia, hypercalcemia, refeeding syndrome and high blood urea, but reduced risk of hyperglycaemia.

CONCLUSIONS

HP intake for children born preterm may be harmful for neonatal metabolism and later neurodisability and has few short-term benefits for growth.

IMPACT STATEMENT

Planned high protein intake after birth for infants born preterm might be harmful for survival, neurodisability and metabolism during infancy and did not improve growth after the neonatal period. Protein intake ≥3.5 g/kg/d should not be recommended for children born preterm.

Use of human milk and fortification in the NICU

Human milk is the gold standard to provide nutritional support for all healthy and sick newborn infants including the very low birth weight (VLBW) infant (<1500 g). It has both nutritional and anti-infective properties which are especially important for these infants at risk for sepsis and necrotizing enterocolitis. Human milk alone is insufficient to meet the nutritional needs for VLBW infants, especially protein and minerals. There is a conundrum between achieving the nutritional, immunologic, developmental, psychological, social, and economic benefit with human milk vs. the inadequate growth with unfortified human milk for VLBW leading to nutritional inadequacy, growth failure and poor neurodevelopmental outcome. The use of multicomponent fortifiers to increase calories and provide additional protein, vitamins, and minerals has been associated with short-term benefits in growth. Most current fortifiers are derived from cow's milk, however there are concerns regarding a possible association between the use of cow's milk-based fortifier and NEC. There is also an exclusive human milk diet with a fortifier derived solely from human milk. There are three approaches for fortifying human milk and include fixed dosage or "blind fortification", adjustable fortification using the blood urea nitrogen as a surrogate for protein nutriture to modify dosage of fortification, and targeted, individualized fortification that is based on periodic human milk analysis.

Medial olivary complex reflex in term newborns with hyperbilirubinemia

OBJECTIVE

This study aimed to compare the integrity of the efferent auditory pathways of newborns that had high hyperbilirubinemia levels and required treatment due to these and healthy newborns.

METHODS

Term-born (37 weeks or later) infants that were brought to the Newborn Polyclinic of the Başkent University Hospital were included in the study. The study included a total of 84 infants including healthy newborns (n = 42) and those that had jaundice and were receiving phototherapy (n = 42). After conducting a general otorhinolaryngology examination on all newborns included in the study, Transient Otoacoustic Emission (TEOAE) test was carried out in the absence and presence of contralateral noise. The obtained contralateral suppression values were compared between the two groups.

RESULTS

In the TEOAE test, the responses obtained at 1 kHz in the newborns receiving phototherapy were found to be lower. The difference between the groups was significant (p = 0.038). The rates of suppression presence at 2 kHz, 2.8 kHz and total OAE were found significantly higher (p < 0.05) in the group not receiving phototherapy. Among the phototherapy-receiving infants, the hyperbilirubinemia levels of the infants in whom suppression was obtained in the contralateral suppression test did not show a statistically significant difference in comparison to those in whom suppression was not obtained (p > 0.05).

CONCLUSION

Based on the obtained data, hyperbilirubinemia may have a disruptive effect on the efferent auditory system in newborns. Consequently, we are of the opinion that, in addition to hearing screening in risky newborn infants, a MOC suppression test would be useful.

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

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

Feeding Interventions for Infants with Growth Failure in the First Six Months of Life: A Systematic Review

(1) Introduction: Current evidence on managing infants under six months with growth failure or other nutrition-related risk is sparse and low quality. This review aims to inform research priorities to fill this evidence gap, focusing on breastfeeding practices. (2) Methods: We searched PubMed, CINAHL Plus, and Cochrane Library for studies on feeding interventions that aim to restore or improve the volume or quality of breastmilk and breastfeeding when breastfeeding practices are sub-optimal or prematurely stopped. We included studies from both low- and middle-income countries and high-income countries. (3) Results: Forty-seven studies met the inclusion criteria. Most were from high-income countries (n = 35, 74.5%) and included infants who were at risk of growth failure at birth (preterm infants/small for gestational age) and newborns with early growth faltering. Interventions included formula fortification or supplementation (n = 31, 66%), enteral feeds (n = 8, 17%), cup feeding (n = 2, 4.2%), and other (n = 6, 12.8%). Outcomes included anthropometric change (n = 40, 85.1%), reported feeding practices (n = 16, 34%), morbidity (n = 11, 23.4%), and mortality (n = 5, 10.6%). Of 31 studies that assessed formula fortification or supplementation, 30 reported anthropometric changes (n = 17 no effect, n = 9 positive, n = 4 mixed), seven morbidity (n = 3 no effect, n = 2 positive, n = 2 negative), five feeding (n = 2 positive, n = 2 no effect, n = 1 negative), and four mortality (n = 3 no effect, n = 1 negative). Of eight studies that assessed enteral feed interventions, seven reported anthropometric changes (n = 4 positive, n = 3 no effect), five feeding practices (n = 2 positive, n = 2 no effect, n = 1 negative), four morbidity (n = 4 no effect), and one reported mortality (n = 1 no effect). Overall, interventions with positive effects on feeding practices were cup feeding compared to bottle-feeding among preterm; nasogastric tube feed compared to bottle-feeding among low birth weight preterm; and early progressive feeding compared to delayed feeding among extremely low birth weight preterm. Bovine/cow milk feeding and high volume feeding interventions had an unfavourable effect, while electric breast pump and Galactagogue had a mixed effect. Regarding anthropometric outcomes, overall, macronutrient fortified formula, cream supplementation, and fortified human milk formula had a positive effect (weight gain) on preterm infants. Interventions comparing human breastmilk/donor milk with formula had mixed effects. Overall, only human milk compared to formula intervention had a positive effect on morbidity among preterm infants, while none of the interventions had any positive effect on mortality. Bovine/cow milk supplementation had unfavourable effects on both morbidity and mortality. (4) Conclusion: Future research should prioritise low- and middle-income countries, include infants presenting with growth failure in the post-neonatal period and record effects on morbidity and mortality outcomes.

Higher versus lower protein intake in formula-fed low birth weight infants

BACKGROUND

The ideal quantity of dietary protein for formula-fed low birth weight infants is still a matter of debate. Protein intake must be sufficient to achieve normal growth without leading to negative effects such as acidosis, uremia, and elevated levels of circulating amino acids.

OBJECTIVES

To determine whether higher (≥ 3.0 g/kg/d) versus lower (< 3.0 g/kg/d) protein intake during the initial hospital stay of formula-fed preterm infants or low birth weight infants (< 2.5 kilograms) results in improved growth and neurodevelopmental outcomes without evidence of short- or long-term morbidity. Specific objectives were to examine the following comparisons of interventions and to conduct subgroup analyses if possible. 1. Low protein intake if the amount was less than 3.0 g/kg/d. 2. High protein intake if the amount was equal to or greater than 3.0 g/kg/d but less than 4.0 g/kg/d. 3. Very high protein intake if the amount was equal to or greater than 4.0 g/kg/d.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 8), in the Cochrane Library (August 2, 2019); OVID MEDLINE Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily, and Ovid MEDLINE(R) (to August 2, 2019); MEDLINE via PubMed (to August 2, 2019) for the previous year; and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (to August 2, 2019). We also searched clinical trials databases and the reference lists of retrieved articles for randomized controlled trials (RCTs) and quasi-randomized trials.

SELECTION CRITERIA

We included RCTs contrasting levels of formula protein intake as low (< 3.0 g/kg/d), high (≥ 3.0 g/kg/d but < 4.0 g/kg/d), or very high (≥ 4.0 g/kg/d) in formula-fed hospitalized neonates weighing less than 2.5 kilograms. We excluded studies if infants received partial parenteral nutrition during the study period, or if infants were fed formula as a supplement to human milk.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

We identified six eligible trials that enrolled 218 infants through searches updated to August 2, 2019. Five studies compared low (< 3 g/kg/d) versus high (3.0 to 4.0 g/kg/d) protein intake using formulas that kept other nutrients constant. The trials were small (n = 139), and almost all had methodological limitations; the most frequent uncertainty was about attrition. Low-certainty evidence suggests improved weight gain (mean difference [MD] 2.36 g/kg/d, 95% confidence interval [CI] 1.31 to 3.40) and higher nitrogen accretion in infants receiving formula with higher protein content (3.0 to 4.0 g/kg/d) versus lower protein content (< 3 g/kg/d), while other nutrients were kept constant. No significant differences were seen in rates of necrotizing enterocolitis, sepsis, or diarrhea. We are uncertain whether high versus low protein intake affects head growth (MD 0.37 cm/week, 95% CI 0.16 to 0.58; n = 18) and length gain (MD 0.16 cm/week, 95% CI -0.02 to 0.34; n = 48), but sample sizes were small for these comparisons. One study compared high (3.0 to 4.0 g/kg/d) versus very high (≥ 4 g/kg/d) protein intake (average intakes were 3.6 and 4.1 g/kg/d) during and after an initial hospital stay (n = 77). Moderate-certainty evidence shows no significant differences in weight gain or length gain to discharge, term, and 12 weeks corrected age from very high protein intake (4.1 versus 3.6 g/kg/d). Three of the 24 infants receiving very high protein intake developed uremia.

AUTHORS' CONCLUSIONS

Higher protein intake (≥ 3.0 g/kg/d but < 4.0 g/kg/d) from formula accelerates weight gain. However, limited information is available regarding the impact of higher formula protein intake on long-term outcomes such as neurodevelopment. Research is needed to investigate the safety and effectiveness of protein intake ≥ 4.0 g/kg/d.

Adiposity and Fat-Free Mass of Children Born with Very Low Birth Weight Do Not Differ in Children Fed Supplemental Donor Milk Compared with Those Fed Preterm Formula

BACKGROUND

Many mothers of very-low-birth-weight (VLBW) infants (<1500 g) are unable to provide sufficient breast milk, and supplemental pasteurized donor human milk (donor milk) or preterm formula is required. The composition of donor milk differs from that of mother's milk and infants fed with donor milk often exhibit slower growth during hospitalization. The long-term impact of nutrient-enriched donor milk on growth, body composition, or blood pressure is unknown.

OBJECTIVE

We aimed to determine the effects of nutrient-enriched donor milk compared with preterm formula on growth, body composition, and blood pressure of children born preterm and with VLBW. Associations with in-hospital mother's milk intake were explored.

METHODS

This study was a follow-up of children at 5.5-y of age who participated in a randomized controlled trial evaluating the effect of nutrient-enriched donor milk (commencing at ≥120 mL·kg-1·d-1) or preterm formula fed as a supplement when mother's milk was unavailable. The trial intervention lasted 90 d or until hospital discharge, whichever occurred first. In this follow-up investigation, differences in total body fat percentage determined by using air displacement plethysmography (primary outcome), fat-free mass, skinfold thickness, waist circumference, BMI z scores, and blood pressure] were evaluated using linear regressions.

RESULTS

Of 316 surviving infants from the earlier trial, 158 (50%) participated in the current study (53% male). Mean ± SD birth weight and gestational age were 1013 ± 264 g and 27.9 ± 2.5 wk. The median (IQR) intervention period was 67.5 d (52.0-91.0 d). Mean ± SD age and BMI z score at follow-up were 5.7 ± 0.2 y and -0.3 ± 1.2. Supplemental nutrient-enriched donor milk, compared to preterm formula, was not associated with growth, body composition, or blood pressure. In-hospital mother's milk intake was positively associated with height z score at 5.5 y (β: 0.07; 95% CI: 0.004, 0.1; P = 0.04).

CONCLUSIONS

Supplemental nutrient-enriched donor milk and preterm formula during initial hospitalization results in comparable long-term growth and body composition in young children born VLBW. This trial was registered at clinicaltrials.gov as NCT02759809 and at isrctn.com as ISRCTN35317141.

Formula versus donor breast milk for feeding preterm or low birth weight infants

BACKGROUND

When sufficient maternal breast milk is not available, alternative forms of enteral nutrition for preterm or low birth weight (LBW) infants are donor breast milk or artificial formula. Donor breast milk may retain some of the non-nutritive benefits of maternal breast milk for preterm or LBW infants. However, feeding with artificial formula may ensure more consistent delivery of greater amounts of nutrients. Uncertainty exists about the balance of risks and benefits of feeding formula versus donor breast milk for preterm or LBW infants.

OBJECTIVES

To determine the effect of feeding with formula compared with donor breast milk on growth and development in preterm or low birth weight (LBW) infants.

SEARCH METHODS

We used the Cochrane Neonatal search strategy, including electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 5), Ovid MEDLINE, Embase, and the Cumulative Index to Nursing and Allied Health Literature (3 May 2019), as well as conference proceedings, previous reviews, and clinical trials.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials (RCTs) comparing feeding with formula versus donor breast milk in preterm or LBW infants.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial eligibility and risk of bias and extracted data independently. We analysed treatment effects as described in the individual trials and reported risk ratios (RRs) and risk differences (RDs) for dichotomous data, and mean differences (MDs) for continuous data, with respective 95% confidence intervals (CIs). We used a fixed-effect model in meta-analyses and explored potential causes of heterogeneity in subgroup analyses. We assessed the certainty of evidence for the main comparison at the outcome level using GRADE methods.

MAIN RESULTS

Twelve trials with a total of 1879 infants fulfilled the inclusion criteria. Four trials compared standard term formula versus donor breast milk and eight compared nutrient-enriched preterm formula versus donor breast milk. Only the five most recent trials used nutrient-fortified donor breast milk. The trials contain various weaknesses in methodological quality, specifically concerns about allocation concealment in four trials and lack of blinding in most of the trials. Most of the included trials were funded by companies that made the study formula.Formula-fed infants had higher in-hospital rates of weight gain (mean difference (MD) 2.51, 95% confidence interval (CI) 1.93 to 3.08 g/kg/day), linear growth (MD 1.21, 95% CI 0.77 to 1.65 mm/week) and head growth (MD 0.85, 95% CI 0.47 to 1.23 mm/week). These meta-analyses contained high levels of heterogeneity. We did not find evidence of an effect on long-term growth or neurodevelopment. Formula feeding increased the risk of necrotising enterocolitis (typical risk ratio (RR) 1.87, 95% CI 1.23 to 2.85; risk difference (RD) 0.03, 95% CI 0.01 to 0.05; number needed to treat for an additional harmful outcome (NNTH) 33, 95% CI 20 to 100; 9 studies, 1675 infants).The GRADE certainty of evidence was moderate for rates of weight gain, linear growth, and head growth (downgraded for high levels of heterogeneity) and was moderate for neurodevelopmental disability, all-cause mortality, and necrotising enterocolitis (downgraded for imprecision).

AUTHORS' CONCLUSIONS

In preterm and LBW infants, moderate-certainty evidence indicates that feeding with formula compared with donor breast milk, either as a supplement to maternal expressed breast milk or as a sole diet, results in higher rates of weight gain, linear growth, and head growth and a higher risk of developing necrotising enterocolitis. The trial data do not show an effect on all-cause mortality, or on long-term growth or neurodevelopment.

Nutrient-enriched formula versus standard formula for preterm infants

BACKGROUND

Preterm infants may accumulate nutrient deficits leading to extrauterine growth restriction. Feeding preterm infants with nutrient-enriched rather than standard formula might increase nutrient accretion and growth rates and might improve neurodevelopmental outcomes.

OBJECTIVES

To compare the effects of feeding with nutrient-enriched formula versus standard formula on growth and development of preterm infants.

SEARCH METHODS

We used the Cochrane Neonatal standard search strategy. This included electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 11), MEDLINE, Embase, and the Cumulative Index to Nursing and Allied Health Literature (until November 2018), as well as conference proceedings, previous reviews, and clinical trials databases.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials that compared feeding preterm infants with nutrient-enriched formula (protein and energy plus minerals, vitamins, or other nutrients) versus standard formula.

DATA COLLECTION AND ANALYSIS

We extracted data using the Cochrane Neonatal standard methods. Two review authors separately evaluated trial quality and extracted and synthesised data using risk ratios (RRs), risk differences, and mean differences (MDs). We assessed certainty of evidence at the outcome level using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods.

MAIN RESULTS

We identified seven trials in which a total of 590 preterm infants participated. Most participants were clinically stable preterm infants of birth weight less than 1850 g. Few participants were extremely preterm, extremely low birth weight, or growth restricted at birth. Trials were conducted more than 30 years ago, were formula industry funded, and were small with methodological weaknesses (including lack of masking) that might bias effect estimates. Meta-analyses of in-hospital growth parameters were limited by statistical heterogeneity. There is no evidence of an effect on time to regain birth weight (MD -1.48 days, 95% confidence interval (CI) -4.73 to 1.77) and low-certainty evidence suggests that feeding with nutrient-enriched formula increases in-hospital rates of weight gain (MD 2.43 g/kg/d, 95% CI 1.60 to 3.26) and head circumference growth (MD 1.04 mm/week, 95% CI 0.18 to 1.89). Meta-analysis did not show an effect on the average rate of length gain (MD 0.22 mm/week, 95% CI -0.70 to 1.13). Fewer data are available for growth and developmental outcomes assessed beyond infancy, and these do not show consistent effects of nutrient-enriched formula feeding. Data from two trials did not show an effect on Bayley Mental Development Index scores at 18 months post term (MD 2.87, 95% CI -1.38 to 7.12; moderate-certainty evidence). Infants who received nutrient-enriched formula had higher Bayley Psychomotor Development Index scores at 18 months post term (MD 6.56. 95% CI 2.87 to 10.26; low-certainty evidence), but no evidence suggested an effect on cerebral palsy (typical RR 0.79, 95% CI 0.30 to 2.07; 2 studies, 377 infants). Available data did not indicate any other benefits or harms and provided low-certainty evidence about the effect of nutrient-enriched formula feeding on the risk of necrotising enterocolitis in preterm infants (typical RR 0.72, 95% CI 0.41 to 1.25; 3 studies, 489 infants).

AUTHORS' CONCLUSIONS

Available trial data show that feeding preterm infants nutrient-enriched (compared with standard) formulas has only modest effects on growth rates during their initial hospital admission. No evidence suggests effects on long-term growth or development. The GRADE assessment indicates that the certainty of this evidence is low, and that these findings should be interpreted and applied with caution. Further randomised trials would be needed to resolve this uncertainty.

Impact of Donor Milk on Short- and Long-Term Growth of Very Low Birth Weight Infants

Mother’s own milk (MOM) reduces the risk of morbidities in very low birth weight (VLBW) infants. When MOM is unavailable, donor breastmilk (DM) is used, with unclear impact on short- and long-term growth. This retrospective analysis compared anthropometric data at six time points from birth to 20–24 months corrected age in VLBW infants who received MOM supplements of preterm formula (n = 160) versus fortified DM (n = 161) during neonatal intensive care unit (NICU) hospitalization. The cohort was 46% female; mean birth weight and gestational age (GA) were 998 g and 27.3 weeks. Multilevel linear growth models assessed changes in growth z-scores short-term (to NICU discharge) and long-term (post-discharge), controlling for amount of DM or formula received in first 28 days of life, NICU length of stay (LOS), birth GA, and sex. Z-scores for weight and length decreased during hospitalization but increased for all parameters including head circumference post-discharge. Short-term growth was positively associated with LOS and birth GA. A higher preterm formula proportion, but not DM proportion, was associated with slower rates of decline in short-term growth trajectories, but feeding type was unrelated to long-term growth. In conclusion, controlling for total human milk fed, DM did not affect short- or long-term growth.

Formula versus donor breast milk for feeding preterm or low birth weight infants

BACKGROUND

When sufficient maternal breast milk is not available, alternative forms of enteral nutrition for preterm or low birth weight (LBW) infants are donor breast milk or artificial formula. Donor breast milk may retain some of the non-nutritive benefits of maternal breast milk for preterm or LBW infants. However, feeding with artificial formula may ensure more consistent delivery of greater amounts of nutrients. Uncertainty exists about the balance of risks and benefits of feeding formula versus donor breast milk for preterm or LBW infants.

OBJECTIVES

To determine the effect of feeding with formula compared with donor breast milk on growth and development in preterm or low birth weight (LBW) infants.

SEARCH METHODS

We used the Cochrane Neonatal search strategy, including electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 6), Ovid MEDLINE, Embase, and the Cumulative Index to Nursing and Allied Health Literature (until 8 June 2017), as well as conference proceedings and previous reviews.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials (RCTs) comparing feeding with formula versus donor breast milk in preterm or LBW infants.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial eligibility and risk of bias and extracted data independently. We analysed treatment effects as described in the individual trials and reported risk ratios (RRs) and risk differences (RDs) for dichotomous data, and mean differences (MDs) for continuous data, with respective 95% confidence intervals (CIs). We used a fixed-effect model in meta-analyses and explored potential causes of heterogeneity in subgroup analyses. We assessed the quality of evidence for the main comparison at the outcome level using "Grading of Recommendations Assessment, Development and Evaluation" (GRADE) methods.

MAIN RESULTS

Eleven trials, in which 1809 infants participated in total, fulfilled the inclusion criteria. Four trials compared standard term formula versus donor breast milk and seven compared nutrient-enriched preterm formula versus donor breast milk. Only the four most recent trials used nutrient-fortified donor breast milk. The trials contain various weaknesses in methodological quality, specifically concerns about allocation concealment in four trials and lack of blinding in most of the trials.Formula-fed infants had higher in-hospital rates of weight gain (mean difference (MD) 2.51, 95% confidence interval (CI) 1.93 to 3.08 g/kg/day), linear growth (MD 1.21, 95% CI 0.77 to 1.65 mm/week) and head growth (MD 0.85, 95% CI 0.47 to 1.23 mm/week). We did not find evidence of an effect on long-term growth or neurodevelopment. Formula feeding increased the risk of necrotising enterocolitis (typical risk ratio (RR) 1.87, 95% CI 1.23 to 2.85; risk difference (RD) 0.03, 95% CI 0.01 to 0.06).The GRADE quality of evidence was moderate for rates of weight gain, linear growth, and head growth (downgraded for high levels of heterogeneity) and was moderate for neurodevelopmental disability, all-cause mortality, and necrotising enterocolitis (downgraded for imprecision).

AUTHORS' CONCLUSIONS

In preterm and LBW infants, feeding with formula compared with donor breast milk, either as a supplement to maternal expressed breast milk or as a sole diet, results in higher rates of weight gain, linear growth, and head growth and a higher risk of developing necrotising enterocolitis. The trial data do not show an effect on all-cause mortality, or on long-term growth or neurodevelopment.

Early postnatal growth and neurodevelopment in children born moderately preterm or small for gestational age at term: A systematic review

BACKGROUND

Clinicians' interest in the long-term effects of early postnatal growth (EPG) is growing. There is compelling evidence linking rapid EPG with later cardiovascular risk, but its neurodevelopmental benefits still remain hypothetical in individuals born moderately preterm (MP) or small for gestational at term (SGAT).

METHODS

The objective was to perform a systematic review of the relationship between EPG before age 3 years and neurodevelopmental outcome for individuals born MP (32-36 weeks' gestational age) or SGAT. Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, 3 independent investigators searched for articles published on this topic in the Web of Science, EMBASE and PubMed from database inception to July 1, 2017. A detailed quality scale was used to evaluate articles.

RESULTS

We selected 19 articles relying on 12 distinct study populations; 7 articles from 3 study populations were considered at moderate or high quality. The lack of standardisation of growth analysis methods prevented performing a meta-analysis. Overall, EPG was positively associated with neurodevelopmental outcome, especially Intelligence Quotient (IQ) when available. In this relationship, the first 6 months of life might be a critical period. Analysis of the few articles investigating the shape of the relationships revealed a non-linear association, with a plateau for IQ with higher weight gain, which suggests a possible ceiling effect.

CONCLUSIONS

A positive association was generally found between EPG and neurodevelopmental outcome for individuals born MP or SGAT. Strategies for future epidemiological studies are suggested to improve the characterisation of this relationship.

Glycosaminoglycanomic profiling of human milk in different stages of lactation by liquid chromatography-tandem mass spectrometry

Glycans in human milk serve several important biological functions that promote infant health. As kind of important glycans, glycosaminoglycans (GAGs) are a complex family of polyanionic carbohydrate, participating in a variety of critical physiological and pathological processes. In this study, the content and the detailed composition of human milk GAGs from Chinese mothers in different stages of lactation, based on a liquid chromatography-tandem mass spectrometry approach was investigated. The results showed that the GAG fraction in the human milk samples was very complex as it was composed of heparan sulfate, chondroitin sulfate, and hyaluronic acid. With lactation extending, the total amount of GAGs in human milk decreased. This study provided an important guide for the demands of GAGs during different stages of lactation. The results were also beneficial for studies on the composition and functional properties of infant formula.

A Fortified Donor Milk Policy is Associated With Improved In-Hospital Head Growth and Weight Gain in Very Low-Birth-Weight Infants

BACKGROUND

Previous research has reported that infants fed donor milk grow slower than those fed formula. However, most of the trials used unfortified donor milk, which limits the ability to generalize the results to current clinical practice.

PURPOSE

To evaluate the impact of early human milk feeding (donor milk and/or mother's own milk) with standard fortification on in-hospital growth of very low-birth-weight infants.

METHODS

This pre-/postretrospective study included selected newborn infants less than 1500 g admitted to a level IV neonatal intensive care unit before and after the introduction of a policy providing donor milk when mother's own milk was not available in sufficient quantity to meet her infant's need. When enteral feeds reached 80 mL/kg per day, all human milk was fortified.

RESULTS

Seventy-two "before" (any formula-fed) and 114 "after" (human milk-fed) infants were enrolled in this study. Infant characteristics and neonatal morbidity were similar in both groups. Outcomes revealed that an initial human milk diet with standard fortification was associated with significantly higher early extrauterine weight gain and head growth in very low-birth-weight infants than a formula-fed diet.

IMPLICATIONS FOR PRACTICE

Very early initiation of fortified breast and/or donor milk feeding can help promote in-hospital head growth and weight gain of preterm infants. Formula may not be appropriate for early use among preterm infants.

IMPLICATIONS FOR RESEARCH

Further large-scale clinical trials are needed to determine the best initiation and composition of enteral feeding for preterm infants.

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

Background: Early nutritional interventions may modulate health risks in preterm-born infants. Previously, we showed that preterm-born infants fed an isocaloric protein- and mineral-enriched postdischarge formula (PDF) from term age to 6-mo corrected age (CA) gained more lean mass than did those fed term formula (TF). Long-term follow-up of randomized nutritional trials is important to test the hypothesis that short-term positive effects on health are sustainable.Objective: The aim of this follow-up study was to compare body size, body composition, and metabolic health at age 8 y in preterm-born children who were randomly assigned to receive either PDF or TF from term age until 6-mo CA.Design: A total of 79 of 152 children (52%) from the original randomized controlled trial were enrolled for follow-up at age 8 y. Weight, height, and head circumference were measured by using standard methods. Body composition, including fat mass, lean mass, bone mineral content, and bone mineral density, was determined by dual-energy X-ray absorptiometry. Blood pressure was measured in the supine position by using an automatic device. Metabolic variables, including glucose, insulin, insulin-like growth factor I, triglycerides, cholesterol, cortisol, and leptin, were measured after an overnight fast. Nutritional habits at age 8 y were assessed by using a 3-d nutritional diary.Results: At age 8 y, no differences were found in body size, body composition, bone variables, and metabolic health variables when comparing children fed PDF with those fed TF. Adjustment for known and possible confounders did not change these results.Conclusions: In this follow-up study in preterm-born children, we showed that the favorable effects of PDF at 6-mo CA either were not maintained or could not be confirmed because of attrition at the age of 8 y. We suggest that future research should focus on nutritional interventions in the pre- and postdischarge period as a continuum rather than as separate entities. This trial was registered at www.trialregister.nl as NTR 2972 (follow-up study [STEP-2 (Study Towards the Effects of Post-discharge Nutrition 2)]) and NTR 55 [original randomized controlled trial (STEP)].

Preterm formula use in the preterm very low birth weight infant

Whereas human milk is the recommended diet for all infants, preterm formulas are indicated for enteral feeding of preterm very low birth weight infants when sufficient maternal breast milk and donor human milk are not available. Feeding with preterm formulas helps to ensure consistent delivery of nutrients. The balance of risks and benefits of feeding preterm formulas versus supplemented maternal and donor breast milk for preterm infants, however, is uncertain. Numerous studies and extensive practice have shown improved growth with preterm formulas, but there is concern for increased risks of necrotizing enterocolitis, possibly from cow milk antigen in the formulas or from different gut microbiomes, increased duration of total parenteral nutrition, and increased rates of sepsis in infants receiving preterm formulas. Furthermore, whereas preterm formulas improve neurodevelopmental outcomes compared to term formulas and unfortified donor milk, they do not produce neurodevelopmental outcomes better than fortified human milk, again indicating that maternal milk has unique properties that formulas need to mimic as closely as possible.

Prevention of postnatal growth restriction by the implementation of an evidence-based premature infant feeding bundle

OBJECTIVE

To develop an evidence-based feeding bundle to safely decrease the rate of PNGR in VLBW infants.

STUDY DESIGN

The bundle was developed and implemented in January 2010, followed by 3 years of monitoring bundle compliance and infant outcomes (days to first feed (FD), days to reach full feeds (FF), and birth-discharge growth trajectories (delta z-score)).

RESULTS

Data were collected on 482 infants (119 pre-bundle). PNGR decreased from 35% to 19% (P<0.01) and weight delta z-score improved from -0.82 to -0.45 (P<0.001). Percentage of infants with head circumference (HC) below 10th percentile at discharge decreased from 21% to 9% (P<0.01) and HC delta z-score improved from -0.65 to -0.17 (P<0.001). FD and FF also decreased significantly. Rates of necrotizing enterocolitis, peak alkaline phosphatase and peak direct bilirubin levels all trended downward.

CONCLUSIONS

An evidence-based, standardized feeding bundle was safe and effective in reducing the rate of PNGR and in improving head growth in VLBW infants.

Formula versus donor breast milk for feeding preterm or low birth weight infants

BACKGROUND

When sufficient maternal breast milk is not available, alternative sources of enteral nutrition for preterm or low birth weight infants are donor breast milk or artificial formula. Donor breast milk may retain some of the non-nutritive benefits of maternal breast milk for preterm or low birth weight infants. However, feeding with artificial formula may ensure more consistent delivery of optimal levels of nutrients. Uncertainty exists about the balance of risks and benefits of feeding formula versus donor breast milk for preterm or low birth weight infants.

OBJECTIVES

To determine the effect of feeding with formula compared with donor breast milk on growth and development in preterm or low birth weight infants.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 3), MEDLINE (1966 to March 2014), EMBASE (1980 to March 2014), CINAHL (1982 to March 2014), conference proceedings and previous reviews.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing feeding with formula versus donor breast milk in preterm or low birth weight infants.

DATA COLLECTION AND ANALYSIS

We extracted data using the standard methods of the Cochrane Neonatal Group, with separate evaluation of trial quality and data extraction by two review authors.

MAIN RESULTS

Nine trials, in which 1070 infants participated, fulfilled the inclusion criteria. Four trials compared standard term formula versus donor breast milk and five compared nutrient-enriched preterm formula versus donor breast milk. Only the two most recent trials used nutrient-fortified donor breast milk. The trials contain various methodological quality weaknesses, specifically uncertainty about adequate allocation concealment methods in three trials and lack of blinding in most of the trials.Formula-fed infants had higher in hospital rates of increase in weight [mean difference (MD): 2.58 (95% confidence interval (CI) 1.98 to 3.71) g/kg/day], length [MD 1.93 (95% CI 1.23 to 2.62) mm/week] and head circumference [MD 1.59 (95% CI 0.95 to 2.24) mm/week]. We did not find evidence of an effect on post-discharge growth rates or neurodevelopmental outcomes. Formula feeding increased the risk of necrotising enterocolitis: typical risk ratio 2.77 (95% CI 1.40 to 5.46); risk difference 0.04 (95% CI 0.02 to 0.07).

AUTHORS' CONCLUSIONS

In preterm and low birth weight infants, feeding with formula compared with donor breast milk results in a higher rate of short-term growth but also a higher risk of developing necrotising enterocolitis. Limited data on the comparison of feeding with formula versus nutrient-fortified donor breast milk are available. This limits the applicability of the findings of this review as nutrient fortification of breast milk is now a common practice in neonatal care. Future trials may compare growth, development and adverse outcomes in infants who receive formula milk versus nutrient-fortified donor breast milk given as a supplement to maternal expressed breast milk or as a sole diet.

Higher versus lower protein intake in formula-fed low birth weight infants

BACKGROUND

The ideal quantity of dietary protein for formula-fed low birth weight infants is still a matter of debate. Protein intake must be sufficient to achieve normal growth without negative effects such as acidosis, uremia, and elevated levels of circulating amino acids.

OBJECTIVES

To determine whether higher (≥ 3.0 g/kg/d) versus lower (< 3.0 g/kg/d) protein intake during the initial hospital stay of formula-fed preterm infants or low birth weight infants (< 2.5 kilograms) results in improved growth and neurodevelopmental outcomes without evidence of short- and long-term morbidity.To examine the following distinctions in protein intake. 1. Low protein intake if the amount was less than 3.0 g/kg/d. 2. High protein intake if the amount was equal to or greater than 3.0 g/kg/d but less than 4.0 g/kg/d. 3. Very high protein intake if the amount was equal to or greater than 4.0 g/kg/d.If the reviewed studies combined alterations of protein and energy, subgroup analyses were to be carried out for the planned categories of protein intake according to the following predefined energy intake categories. 1. Low energy intake: less than 105 kcal/kg/d. 2. Medium energy intake: greater than or equal to 105 kcal/kg/d and less than or equal to 135 kcal/kg/d. 3. High energy intake: greater than 135 kcal/kg/d.As the Ziegler-Fomon reference fetus estimates different protein requirements for infants based on birth weight, subgroup analyses were to be undertaken for the following birth weight categories. 1. < 800 grams. 2. 800 to 1199 grams. 3. 1200 to 1799 grams. 4. 1800 to 2499 grams.

SEARCH METHODS

The standard search methods of the Cochrane Neonatal Review Group were used. MEDLINE, CINAHL, PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library) were searched.

SELECTION CRITERIA

Randomized controlled trials contrasting levels of formula protein intake as low (< 3.0 g/kg/d), high (≥ 3.0 g/kg/d but < 4.0 g/kg/d), or very high (≥ 4.0 g/kg/d) in formula-fed hospitalized neonates weighing less than 2.5 kilograms were included. Studies were excluded if infants received partial parenteral nutrition during the study period or were fed formula as a supplement to human milk. Studies in which nutrients other than protein also varied were added in a post-facto analysis.

DATA COLLECTION AND ANALYSIS

The standard methods of the Cochrane Neonatal Review Group were used.

MAIN RESULTS

Five studies compared low versus high protein intake. Improved weight gain and higher nitrogen accretion were demonstrated in infants receiving formula with higher protein content while other nutrients were kept constant. No significant differences were seen in rates of necrotizing enterocolitis, sepsis, or diarrhea.One study compared high versus very high protein intake during and after an initial hospital stay. Very high protein intake promoted improved gain in length at term, but differences did not remain significant at 12 weeks corrected age. Three of the 24 infants receiving very high protein intake developed uremia.A post-facto analysis revealed further improvement in all growth parameters in infants receiving formula with higher protein content. No significant difference in the concentration of plasma phenylalanine was noted between high and low protein intake groups. However, one study (Goldman 1969) documented a significantly increased incidence of low intelligence quotient (IQ) scores among infants of birth weight less than 1300 grams who received a very high protein intake (6 to 7.2 g/kg).

AUTHORS' CONCLUSIONS

Higher protein intake (≥ 3.0 g/kg/d but < 4.0 g/kg/d) from formula accelerates weight gain. However, limited information is available regarding the impact of higher formula protein intake on long-term outcomes such as neurodevelopmental abnormalities. Available evidence is not adequate to permit specific recommendations regarding the provision of very high protein intake (> 4.0 g/kg/d) from formula during the initial hospital stay or after discharge.

Structural and functional characteristics of bovine milk protein glycosylation

Most secreted and cell membrane proteins in mammals are glycosylated. Many of these glycoproteins are also prevalent in milk and play key roles in the biomodulatory properties of milk and ultimately in determining milk's nutritional quality. Although a significant amount of information exists on the types and roles of free oligosaccharides in milk, very little is known about the glycans associated with milk glycoproteins, in particular, the biological properties that are linked to their presence. The main glycoproteins found in bovine milk are lactoferrin, the immunoglobulins, glycomacropeptide, a glycopeptide derived from κ-casein, and the glycoproteins of the milk fat globule membrane. Here, we review the glycoproteins present in bovine milk, the information currently available on their glycosylation and the biological significance of their oligosaccharide chains.

Satiety responsiveness and eating behavior among Chilean adolescents and the role of breastfeeding

Objective

To determine patterns of satiety responsiveness and its relationship to eating in the absence of hunger (EAH), in a cohort of adolescents. We also assessed whether sex, BMI and duration of breastfeeding, during infancy, predicted satiety responsiveness and eating behavior at 16 years.

Methods

Adolescents (n=576) from a longitudinal cohort, that began as an iron deficiency anemia preventive trial, participated in an unlimited breakfast after an overnight fast, and reported satiety response on a visual analogue scale after the meal, followed by an EAH procedure. Height, weight and body composition were measured before breakfast. Latent profile analysis generated profiles that captured individual differences in satiety responsiveness. Multivariable regressions, adjusted for potential confounders, evaluated the association between: 1) satiety responsiveness and EAH, and 2) breastfeeding in infancy, satiety responsiveness and EAH in adolescence.

Results

Participants were on average 16.7-years-old, 48% female, 37% overweight/obese and 76% were breastfed as the sole source of milk for < 6 months. We found three latent profiles of satiety responsiveness: 1. “responsive” (49%); 2. “not responsive” (41%); 3. “still hungry” (10%). Participants in the “not responsive” or “still hungry” profile were more likely to eat during the EAH procedure (OR=2.5, 95%CI 1.8–3.6). Being breastfed for < 6 months was related to higher odds of being in the “not responsive” or “still hungry” profile (OR 1.8, 95%CI 1.2–2.6) and EAH (OR=2.2, 95% CI 1.4–3.3). Satiety responsiveness was not influenced by sex and overweight/obesity.

Conclusion

After an ad libitum meal, we found varied satiety responses, which related to EAH. Furthermore, shorter breastfeeding duration was associated with poorer satiety response and higher consumption during an EAH procedure. Understanding if breastfeeding influences the development of satiety responsiveness and eating behavior may be important in an era characterized by abundant calorie-dense foods and a plethora of environmental cues promoting consumption.

Multinutrient fortification of human breast milk for preterm infants following hospital discharge

BACKGROUND

Preterm infants are usually growth restricted at hospital discharge. Feeding preterm infants after hospital discharge with multinutrient fortified breast milk rather than unfortified breast milk may facilitate more rapid catch-up growth and improve neurodevelopmental outcomes.

OBJECTIVES

To determine the effect of feeding preterm infants following hospital discharge with multinutrient fortified human breast milk versus unfortified breast milk on growth and development.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group. This included electronic searches of the Cochrane Central Register of Controlled Trials Register (CENTRAL, The Cochrane Library, 2012, Issue 3), MEDLINE, EMBASE and CINAHL (until August 2012), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that compared feeding preterm infants following hospital discharge with multinutrient fortified breast milk compared with unfortified human breast milk.

DATA COLLECTION AND ANALYSIS

We extracted data using the standard methods of the Cochrane Neonatal Review Group with separate evaluation of trial quality and data extraction by two review authors and synthesis of data using risk ratio, risk difference and mean difference.

MAIN RESULTS

We identified two small trials involving a total of 246 infants. These did not provide evidence that multinutrient fortification of breast milk for three to four months after hospital discharge affected rates of growth during infancy. One trial assessed infants at 18 months corrected age and did not find any statistically significant effects on neurodevelopmental outcomes.

AUTHORS' CONCLUSIONS

The limited available data do not provide convincing evidence that feeding preterm infants with multinutrient fortified breast milk compared with unfortified breast milk following hospital discharge affects important outcomes including growth rates during infancy. There are no data on long-term growth. Since fortifying breast milk for infants fed directly from the breast is logistically difficult and has the potential to interfere with breast feeding, it is important to determine if mothers would support further trials of this intervention.

Characteristics of the first human milk bank in Taiwan

BACKGROUND

The benefits of feeding human milk to infants, even in prematurity, have been well documented. Well-organized donor milk processing has made the milk bank a good source of nutrition for premature or sick infants if their own mother's milk is not sufficient or suitable. The Taipei City Hospital Milk Bank was established in 2005 and is the first nonprofit human milk bank to operate in Taiwan.

METHODS

The milk bank has adopted standards of practice laid down by the Human Milk Banking Association of North America and United Kingdom Association for Milk Banking. The clinical characteristics of the eligible milk donors, the recipients, and the donor milk were reviewed retrospectively.

RESULTS

In the past 6 years, 816 eligible donors donated a total or 13,900 L (mean 17.03 L/donor) of breast milk. The mean age of these donors was 31.3 years, and 79.7% of them had college education. Most had term delivery (91.2%), with mean birth weight of their babies being 3120 g; 68.9% of the donors were primiparas. A total of 551 infants had received bank milk, with these indications: prematurity (65.4%), malabsorption (7.6%), feeding intolerance (7.2%), maternal illness (5.1%) and post-surgery (4.6%). The pass rate of raw donor milk was around 72.1%. The most common reasons to discard raw milk were Gram-negative rods contamination (72.8%) and ≥10 colony-forming units/mL of coagulase-negative Staphylococcus (62.3%). Only 0.63% of donor milk post pasteurization showed bacterial growth.

CONCLUSION

Proper management and operation of a human milk bank can support breastfeeding, and provide a safe alternative to artificial formula for feeding preterm or ill infants in Taiwan. Sustainability of the milk bank needs more propagation and financial support by health authorities.

Growth monitoring of low birthweight infants: what references to use?

Growth charts are the mainstay of monitoring growth in babies who were born small or preterm. A variety of different charts are available, each with specific limitations. Most birthweight centile charts underestimate growth restriction in preterm babies and there are few good charts for monitoring longitudinal growth in preterm babies; it is important to be aware of the limitations of using cross-sectional data for monitoring longitudinal growth. Customised centile charts of fetal growth are used increasingly for antenatal monitoring for small-for-gestational age fetuses despite a lack of robust evidence. It is also unclear whether customised centile charts should be used for assessing birthweight, particularly in babies born at term. Faltering post-natal growth in preterm babies is very common but need not be universal with close attention to nutrition. Monitoring of growth trajectories through infancy following either fetal growth restriction or post-natal faltering growth is important to ensure proportional growth, particularly during periods of accelerated growth. This review will discuss these issues in the context of current practice in Australia and New Zealand.

Curvas de crescimento e perfil dietético de recém-nascidos pré-termo com peso adequado para a idade gestacional durante a hospitalização

OBJETIVO: Elaborar curvas de crescimento e estabelecer o perfil dietético de recém-nascidos pré-termo com peso adequado para a idade gestacional (AIG) durante a internação após o nascimento. MÉTODOS: Estudo coorte retrospectivo e descritivo de recém-nascidos pré-termo AIG, nascidos entre janeiro de 2006 e dezembro de 2007, internados em um hospital de Viçosa, Minas Gerais, Brasil. Foram coletadas informações sobre as medidas antropométricas ao nascer e sua evolução (peso diário e comprimento, perímetro cefálico e torácico semanal) e sobre a evolução diária da dieta. A partir dos dados coletados foram construídas curvas de crescimento referentes às medidas ao nascer e àquelas no pós-natal, em função da idade gestacional, as quais foram comparadas às referências nacionais e internacionais. Além da análise descritiva, foram feitos ajustes por funções polinomiais de terceiro grau para modelação das curvas de crescimento. RESULTADOS: Foram incluídos no estudo 68 recém-nascidos pré-termo AIG, com idade gestacional média de 33,2±2,6 semanas. Observou-se uma grande concordância entre as curvas do percentil 50 das quatro medidas antropométricas ao nascer em estudo e as curvas do percentil 50 de crescimento intrauterino. Entretanto, as curvas do percentil 50 das medidas antropométricas no período pós-natal foram similares às curvas do percentil 10 ou -2 desvios-padrão de crescimento intrauterino. Durante a internação, 84,6% das crianças receberam leite materno; entretanto, a mediana encontrada do percentual dos dias de uso do leite materno em função do tempo de internação foi de somente 50% (2 a 100%). CONCLUSÕES: Os ganhos antropométricos durante o período de internação não reproduzem o ganho intrauterino. Observou-se a necessidade de maior oferta do leite materno durante o período de internação.

Preterm infants fed nutrient-enriched formula until 6 months show improved growth and development

BACKGROUND

The purpose of the present study was to determine the effect of feeding nutrient-enriched preterm formula to preterm infants until 6 months' corrected age (CA) on growth and development in the first 18 months of life.

METHODS

Very low-birthweight preterm infants were fed preterm formula until term (40 weeks CA). Infants were then assigned to one of three groups and were fed term formula until 6 months' CA (group 1, n= 29); preterm formula to 3 months' CA and then term formula to 6 months' CA (group 2, n= 30); or preterm formula until 6 months' CA (group 3, n= 31). Anthropometry was performed at term, 3, 6, 9, 12, 15, and at s18 months' CA. Mental and psychomotor development were assessed using the Bayley Scales of Infant Development II at 18 months' CA.

RESULTS

Although body weight, length, head circumference and z score for CA at term in group 3 were significantly lower than those of groups 1 and 2, growth rates of these parameters were significantly higher in group 3 up to 18 months CA', as compared to groups 1 and 2. The mental developmental index and psychomotor developmental index of the Bayley test were not significantly different between the three groups.

CONCLUSIONS

Very low-birthweight preterm infants fed nutrient-enriched preterm formula until 6 months' CA demonstrated significantly improved growth rates for bodyweight, length and head circumference, and comparable mental and psychomotor development throughout the first 18 months of life.

Daily physical activity in low-risk pre-term infants: positive impact on bone strength and mid-upper arm circumference

BACKGROUND

Prevention of pre-term osteopenia is important because it results in ventilator dependency, fractures in long bones, softening of the ribs or respiratory failure due to bone breaks in newborns.

AIM

The aim of this study was to evaluate the changes in bone strength and anthropometric indices of very low birth-weight (VLBW) pre-term infants undergoing daily physical activity.

SUBJECTS AND METHODS

Forty VLBW and low-risk pre-term infants (n intervention group = 20, n control group = 20) with a birth weight of 800-1600 g and gestational age of 26-32 weeks were recruited. Pre-term infants in the control group were provided with standard nursing care whereas those in the intervention group received a daily physical activity programme in addition to standard nursing care during the study. Before and after the study, anthropometric indices and tibial speed of sound (SOS) values were measured.

RESULTS

In this study the tibial SOS values were found to be increased in the intervention group (p < 0.001) and decreased in the control group (p = 0.002). The increase in percentage of the mid-upper arm circumference of infants was significantly higher in the intervention group than in the control group (p < 0.001).

CONCLUSION

A daily physical activity programme increased SOS values of the tibia and mid-upper arm circumference in VLBW pre-term infants.

Multinutrient fortification of human breast milk for preterm infants following hospital discharge

BACKGROUND

Preterm infants are usually growth restricted at hospital discharge. Feeding preterm infants after hospital discharge with multinutrient fortified breast milk rather than unfortified breast milk may facilitate more rapid catch-up growth and improve neurodevelopmental outcomes.

OBJECTIVES

To determine the effect of feeding with multinutrient fortified human breast milk versus unfortified breast milk on growth and development in preterm or low birth weight infants following hospital discharge.

SEARCH STRATEGY

The standard search strategy of the Cochrane Neonatal Review Group was used. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 4, 2010), MEDLINE (1966 to April 2010), EMBASE (1980 to April 2010), CINAHL (1982 to April 2010), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that compared feeding preterm infants following hospital discharge with multinutrient fortified breast milk compared with unfortified human breast milk.

DATA COLLECTION AND ANALYSIS

The standard methods of the Cochrane Neonatal Review Group were used, with separate evaluation of trial quality and data extraction by two review authors.

MAIN RESULTS

One small trial (N = 39) was identified. Multinutrient fortification of breast milk for 12 weeks after hospital discharge resulted in higher rates of growth during infancy. At 12 months corrected age, weight (mean difference 1187g, 95% confidence interval (CI) 259, 2115 g), length (3.8 cm, 95%CI 1.2, 6.4 cm) and head circumference (1.0 cm, 95%CI 0.1, 1.9 cm) were statistically significantly greater in the intervention group. No evidence of an effect on neurodevelopmental assessments at 18 months corrected age was found.

AUTHORS' CONCLUSIONS

The limited available data suggest that feeding preterm infants following hospital discharge with multinutrient fortified breast milk compared with unfortified breast milk increases growth rates during infancy. The importance of these effects on long-term growth and development is unclear and deserves further assessment in randomised controlled trials. Since fortifying breast milk for infants fed directly from the breast is logistically difficult and has the potential to interfere with breast feeding, it is important to determine if mothers would support further trials of this intervention.

Donor human milk in preterm infant feeding: evidence and recommendations

In preterm infants, feeding with human milk (HM) is a very effective intervention for the prevention of infections and necrotizing enterocolitis (NEC), and for potentially improved neurocognitive and cardiovascular outcomes in the long-term. Hospitals and physicians are advised to recommend HM for preterm and other high-risk infants either by direct breastfeeding and/or using the mother's own expressed milk. Donor HM is the preferred feeding when the mother's own milk is not available in sufficient quantity. While in some countries donor HM has been considered an effective tool in the delivery of health care to infants, skepticism regarding its nutritional and immunological quality has limited its distribution in other countries. The purpose of this paper is to summarize the clinical benefits of donor HM in preterm infants, and to discuss common concerns limiting its distribution as standard care. Clinically, the use of donor HM has been shown to prevent NEC, reduce feeding intolerance and improve long-term outcomes in premature infants. Common concerns, such as slow growth and loss of important biological components of donor HM due to storage and pasteurization, should not be a reason for denial of donor milk. Optimization of banking procedures and of HM fortification is available and should be applied. Banked donor milk should be promoted as standard component of health care for premature infants.

Parental influence on children's early eating environments and obesity risk: implications for prevention

Most childhood obesity prevention efforts have focused on school-age children and adolescents and have had limited success. We argue that the first years of life, including the prenatal period, the postnatal suckling period and the transition to the modified adult diet, may provide opportunities for preventive interventions. These early periods are characterized by high plasticity and rapid transitions, and parents have a high degree of control over children's environments and experiences. Observational and experimental evidence reveal persistent effects of early environments on eating behavior and obesity risk, suggesting that interventions should be tested during these early periods. The central task parents have in early development points to their potential as key targets and agents of change in early preventive interventions. In this paper, we review evidence of early environmental effects on children's eating and obesity risk, highlighting ways that parental feeding practices and parents' own behaviors impact these outcomes and calling for further experimental research to elucidate whether these factors are indeed promising targets for childhood obesity preventive interventions.

Multicomponent fortification of human breast milk for preterm infants following hospital discharge

BACKGROUND

Preterm infants are usually growth restricted at hospital discharge. Feeding preterm infants after hospital discharge with nutrient-fortified breast milk (rather than unfortified breast milk) may facilitate more rapid catch-up growth and improve neurodevelopmental outcomes.

OBJECTIVES

To determine the effect of feeding with multicomponent fortified human breast milk versus unfortified breast milk on growth and development on preterm or low birth weight infants following hospital discharge.

SEARCH STRATEGY

The standard search strategy of the Cochrane Neonatal Review Group was used. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2007), MEDLINE (1966 - May 2007), EMBASE (1980 - May 2007), CINAHL (1982 - May 2007), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that compared feeding preterm infants following hospital discharge with multicomponent fortified breast milk compared with unfortified human breast milk.

DATA COLLECTION AND ANALYSIS

The standard methods of the Cochrane Neonatal Review Group were used, with separate evaluation of trial quality and data extraction by two review authors.

MAIN RESULTS

No eligible trials were identified.

AUTHORS' CONCLUSIONS

There are no data from randomised controlled trials to determine whether feeding preterm infants following hospital discharge with multicomponent-fortified breast milk compared with unfortified breast milk affects growth and development. Given the potential for nutrient fortification to affect growth and development, this intervention may merit further assessment. Since fortifying breast milk for infants fed directly from the breast is logistically difficult (and has the potential to interfere with breast-feeding), it would be important to determine if mothers would support a trial of this intervention. It may be that a trial should first focus on infants who are not able to consume ad libitum quantities of breast milk directly from the breast, who have poor growth or nutritional status, or who have on-going additional metabolic requirements.

Formula milk versus donor breast milk for feeding preterm or low birth weight infants

BACKGROUND

When sufficient maternal breast milk is not available, the alternative sources of enteral nutrition for preterm or low birth weight infants are donor breast milk or artificial formula milk. Feeding preterm or low birth weight infants with formula milk might increase nutrient input and growth rates. However, since feeding with formula milk may be associated with a higher incidence of feeding intolerance and necrotising enterocolitis, this may adversely affect growth and development.

OBJECTIVES

To determine the effect of formula milk compared with donor human breast milk on growth and development in preterm or low birth weight infants.

SEARCH STRATEGY

The standard search strategy of the Cochrane Neonatal Review Group was used. This included electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2007), MEDLINE (1966 - May 2007), EMBASE (1980 - May 2007), CINAHL (1982 - May 2007), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised controlled trials comparing feeding with formula milk versus donor breast milk in preterm or low birth weight infants.

DATA COLLECTION AND ANALYSIS

Data were extracted using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by two reviewer authors, and synthesis of data using relative risk, risk difference and weighted mean difference.

MAIN RESULTS

Eight trials fulfilled the inclusion criteria. Only one trial used nutrient-fortified donor breast milk. Enteral feeding with formula milk compared with donor breast milk resulted in higher rates of growth in the short term. There was no evidence of an effect on long-term growth rates or neurodevelopmental outcomes. Meta-analysis of data from five trials demonstrated a statistically significantly higher incidence of necrotising enterocolitis in the formula fed group: typical relative risk 2.5 (95% confidence interval 1.2, 5.1); typical risk difference: 0.03 (95% confidence interval 0.01, 0.06; number needed to harm: 33 (95% confidence interval 17, 100).

AUTHORS' CONCLUSIONS

In preterm and low birth weight infants, feeding with formula milk compared with donor breast milk results in a higher rate of short-term growth but also a higher risk of developing necrotising enterocolitis. There are only limited data on the comparison of feeding with formula milk versus nutrient-fortified donor breast milk. This limits the applicability of the findings as nutrient fortification of breast milk is now a common practice in neonatal care. Future trials may compare growth, development and adverse outcomes in infants who receive formula milk versus nutrient-fortified donor breast milk given as a supplement to maternal expressed breast milk or as a sole diet.

Nutrient-enriched formula versus standard term formula for preterm infants following hospital discharge

BACKGROUND

Preterm infants are often growth-restricted at hospital discharge. Feeding infants after hospital discharge with nutrient-enriched formula rather than standard term formula might facilitate "catch-up" growth and improve development.

OBJECTIVES

To determine the effect of feeding nutrient-enriched formula compared with standard term formula on growth and development for preterm infants following hospital discharge.

SEARCH STRATEGY

The standard search strategy of the Cochrane Neonatal Review Group were used. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2007), MEDLINE (1966 - May 2007), EMBASE (1980 - May 2007), CINAHL (1982 - May 2007), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that compared the effect of feeding preterm infants following hospital discharge with nutrient-enriched formula compared with standard term formula.

DATA COLLECTION AND ANALYSIS

Data was extracted using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by two authors, and synthesis of data using weighted mean difference and a fixed effects model for meta-analysis.

MAIN RESULTS

Seven trials were found that were eligible for inclusion. These recruited a total of 631 infants and were generally of good methodological quality. The trials found little evidence that feeding with nutrient-enriched formula milk affected growth and development. Because of differences in the way individual trials measured and presented outcomes, data synthesis was limited. Growth data from two trials found that, at six months post-term, infants fed with nutrient-enriched formula had statistically significantly lower weights [weighted mean difference: -601 (95% confidence interval -1028, -174) grams], lengths [-18.8 (-30.0, -7.6) millimetres], and head circumferences [-10.2 ( -18.0, -2.4) millimetres], than infants fed standard term formula. At 12 to 18 months post-term, meta-analyses of data from three trials did not find any statistically significant differences in growth parameters. However, examination of these meta-analyses demonstrated statistical heterogeneity. Meta-analyses of data from two trials did not reveal a statistically significant difference in Bayley Mental Development or Psychomotor Development Indices. There are not yet any data on growth or development through later childhood.

AUTHORS' CONCLUSIONS

The available data do not provide strong evidence that feeding preterm infants following hospital discharge with nutrient-enriched formula compared with standard term formula affects growth rates or development up to 18 months post-term.

Nutrient-enriched formula milk versus human breast milk for preterm infants following hospital discharge

BACKGROUND

Preterm infants are often growth-restricted at hospital discharge. Feeding infants after hospital discharge with nutrient-enriched formula milk instead of human breast milk might facilitate "catch-up" growth and improve development.

OBJECTIVES

To determine the effect of feeding nutrient-enriched formula compared with human breast milk on growth and development of preterm infants following hospital discharge.

SEARCH STRATEGY

The standard search strategy of the Cochrane Neonatal Review Group was used. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2007), MEDLINE (1966 - May 2007), EMBASE (1980 - May 2007), CINAHL (1982 - May 2007), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that compared feeding preterm infants following hospital discharge with nutrient-enriched formula compared with human breast milk.

DATA COLLECTION AND ANALYSIS

The standard methods of the Cochrane Neonatal Review Group were used, with separate evaluation of trial quality and data extraction by two review authors.

MAIN RESULTS

No eligible trials were identified.

AUTHORS' CONCLUSIONS

There are no data from randomised controlled trials to determine whether feeding preterm infants following hospital discharge with nutrient-enriched formula milk versus human breast milk affects growth and development. Mothers who wish to breast feed, and their health care advisors, would require very clear evidence that feeding with a nutrient-enriched formula milk had major advantages for their infants before electing not to feed (or to reduce feeding) with maternal breast milk. If evidence from trials that compared feeding preterm infants following hospital discharge with nutrient-enriched versus standard formula milk demonstrated an effect on growth or development, then this might strengthen the case for undertaking trials of nutrient-enriched formula milk versus human breast milk.

Effect of high volume intake of mother's milk with an individualized supplementation of minerals and protein on early growth of preterm infants <28 weeks of gestation

OBJECTIVE

A prospective study was designed to evaluate the effects of high volume intake of mother's milk fortified (FMM) with an individualized supplementation of minerals and protein on tolerance, short-term somatic growth, serum concentrations of calcium, phosphorus, alkaline phosphatase, and total plasma protein in healthy preterm infants below 28 weeks of gestation.

METHODS

Sixty preterm infants were included in the FMM group, for having received >80% or more of the milk volume as their own mother's milk at 3 weeks of postnatal age to 38 weeks of corrected gestational age. This group was compared with 60 preterm infants fed exclusively preterm formula milk (PF). Intended fluid volume of the FMM group was approximately 200 and 150-170 mL/kg/d in the PF group. Mother's milk was supplemented with the goal of a daily protein intake of 3.5-4 g/kg/d. Phosphorus was supplemented from 15.5 to 31 mg per 100mL mother's milk.

RESULTS

Both feeding regimes were well tolerated. At the end of the study, nutritional management in both groups resulted in a body weight between the 25th and 50th percentiles of intrauterine growth expectations. Serum values of electrolytes, alkaline phosphatase, plasma protein, blood urea nitrogen, and urinary mineral excretion did not differ significantly between the two groups at study entry as well as at the end of the investigation.

CONCLUSIONS

Mother's milk fed at higher volumes with an individualized fortification of minerals and protein provides sufficient nutrients to allow adequate growth of preterm infants <28 weeks of gestation.

Breast-fed low-birth-weight premature neonates: developmental assessment and nutritional intake in the first 6 months of life

A secondary analysis of a randomized clinical trial in which the control group received routine breast-feeding care, consisted of women planning to breast-feed their low-birth-weight (LBW) premature infants, was conducted. The purpose of this secondary analysis was to examine the nutrition of healthy premature LBW infants and its impact on their development. A longitudinal prospective descriptive design was implemented measuring the same group of 50 healthy breast-feeding LBW premature infants from birth to 6 months corrected age. Developmental screening was performed at 6 months corrected age using the Bayley Scales of Infant Development to assess development in Mental scale, Motor scale, and Infant Behavioral record. Repeated measures analyses of variance were performed between the 3 gestational age groups and between the breast-fed and non-breast-fed groups. Bayley Scales of Infant Development Mental and Motor scales showed significant differences between the breast-fed and non-breast-fed groups at 6 months corrected age (P < .014 and P < .013, respectively). The nutrition of healthy premature LBW infants over time was recorded and described. Nutritional assessment indicated that human milk intake in some quantity decreased from 40 weeks corrected age to 6 months corrected age: 70% to 26%. These findings can be utilized in anticipatory guidance when caring for neonates and mothers in the neonatal intensive care unit to encourage mothers to provide their own milk and strive to breast-feed.

Donor breast milk versus infant formula for preterm infants: systematic review and meta-analysis

OBJECTIVES

To compare the effect of donor breast milk with infant formula in preterm infants. Separate comparisons with formula were made for donor breast milk that was: (1) given as a sole diet; (2) given as a supplement to mother's own breast milk; and (3) fortified with macronutrients and micronutrients. The main outcomes were death, necrotising enterocolitis (NEC), infection, growth and development.

DATA SOURCES

Electronic databases-Cochrane, CENTRAL, MEDLINE, EMBASE, CINAHL, and HMIC: DH.

REVIEW METHODS

Systematic review and meta-analysis of trials and observational studies of preterm or low birthweight infants.

RESULTS

Seven studies (including five randomised controlled trials), all from the 1970s and 1980s, fulfilled the inclusion criteria. All studies compared the effect of sole donor breast milk with formula (combined n = 471). One of these also compared the effect of donor breast milk with formula given as a supplement to mother's own milk (n = 343). No studies examined fortified donor breast milk. A meta-analysis based on three studies found a lower risk of NEC in infants receiving donor breast milk compared with formula (combined RR 0.21, 95% CI 0.06 to 0.76). Donor breast milk was associated with slower growth in the early postnatal period, but its long-term effect is unclear.

CONCLUSION

Donor breast milk is associated with a lower risk of NEC and slower growth in the early postnatal period, but the quality of the evidence is limited. Further research is needed to confirm these findings and measure the effect of fortified or supplemented donor breast milk.

Banking for the future: investing in human milk

Perspective on the paper by Boyd et al (see page F169 )

Enteral nutrition for premature infants: the role of human milk

Nutrition support of the premature infant must be designed to compensate for metabolic and gastrointestinal immaturity, immunologic insufficiency, and the demands of associated medical conditions. The beneficial effects of human milk extend to the feeding of premature infants. Although human milk enhances immunity, nutritional concerns arise because the milk might not meet the expanded nutrient requirements of very low birth weight premature infants. Human milk fortifiers are available to provide optimum nutrition. This chapter summarizes the benefits and limitations of human milk for the premature infant.

Promotion of faster weight gain in infants born small for gestational age: is there an adverse effect on later blood pressure?

BACKGROUND

Being born small for gestational age is associated with later risk factors for cardiovascular disease, such as high blood pressure. Promotion of postnatal growth has been proposed to ameliorate these effects. There is evidence in animals and infants born prematurely, however, that promotion of growth by increased postnatal nutrition increases rather than decreases later cardiovascular risk. We report the long-term impact of growth promotion in term infants born small for gestational age (birth weight <10th percentile).

METHODS AND RESULTS

Blood pressure was measured at 6 to 8 years in 153 of 299 (51%) of a cohort of children born small for gestational age and randomly assigned at birth to receive either a standard or a nutrient-enriched formula. The enriched formula contained 28% more protein than standard formula and promoted weight gain. Diastolic and mean (but not systolic) blood pressure was significantly lower in children assigned to standard compared with nutrient-enriched formula (unadjusted mean difference for diastolic blood pressure, -3.2 mm Hg; 95% CI, -5.8 to -0.5; P=0.02) independent of potential confounding factors (adjusted difference, -3.5 mm Hg; P=0.01). In observational analyses, faster weight gain in infancy was associated with higher later blood pressure.

CONCLUSIONS

In the present randomized study targeted to investigate the effect of early nutrition on long-term cardiovascular health, we found that a nutrient-enriched diet increased later blood pressure. These findings support an adverse effect of relative "overnutrition" in infancy on long-term cardiovascular disease risk, have implications for the early origins of cardiovascular disease hypothesis, and do not support the promotion of faster weight gain in infants born small for gestational age.

A strategy for annotating the human milk glycome

Oligosaccharides in human milk represent a group of bioactive molecules that have evolved to be an abundant and diverse component of human milk, even though they have no direct nutritive value to the infant. A recent hypothesis proposes that they could be substrates for the development of the intestinal microflora and the mucosal immune system. The inability to determine the exact composition of these oligosaccharides limits research and the ability to understand their biological functions. Oligosaccharides isolated from the lipids and proteins of individual human milk samples were analyzed by a combination of techniques including microchip liquid chromatography mass spectrometry (HPLC-Chip/MS) and matrix-assisted laser desorption/ionization Fourier transform ion cyclotron resonance mass spectrometry (MALDI-FT ICR MS). Accurate mass measurements obtained using an orthogonal time-of-flight (o-TOF) mass spectrometry provided oligosaccharide composition for approximately 200 individual molecular species. Comparison of HPLC-Chip/MS profiles from five different women revealed variations in milk oligosaccharide compositions. HPLC-Chip/MS profiling provides a method for routinely identifying milk oligosaccharides. Tandem MS in combination with exoglycosidase digestion provides unambiguous differentiation of structural isomers.

Growth and the premature baby

There is considerable evidence to show that babies born prematurely have poor postnatal growth, and the more premature the baby, the greater the impairment is likely to be and the longer it will persist. Nutrition has been shown to play an important part in this, but adequate nutrition is difficult, if not impossible, to achieve in these infants. In the most immature infants, growth retardation may continue for many months and catch-up may be delayed and incomplete. Evidence from long-term studies suggests that preterm infants will be shorter and lighter than term controls and that reduced stature and head size may be linked with lower intelligence. Although there is evidence linking better growth to better neurodevelopmental outcome, with reports suggesting that this can be achieved with dietary manipulation, there are also data that suggest that there could be a link between increased postnatal growth and increased morbidity and mortality in later childhood and adult life. Here, we provide an overview of current understanding of growth impairment in infants born prematurely and the effects in later life.

Higher versus lower protein intake in formula-fed low birth weight infants

BACKGROUND

The ideal quantity of dietary protein for formula-fed low birth weight infants < 2.5 kilograms is still a matter of controversy and debate. In premature infants, the protein intake must be sufficient to achieve normal growth without negative effects such as acidosis, uremia, and elevated levels of circulating amino acids (e.g. phenylalanine levels). This systematic review evaluates the benefits and risks of higher (>= 3.0 g/kg/day) versus lower (< 3.0 g/kg/day) protein intakes during the initial hospital stay of formula-fed preterm infants < 2.5 kilograms.

OBJECTIVES

To determine whether higher (>= 3.0 g/kg/day) versus lower (< 3.0 g/kg/day) protein intakes during the initial hospital stay of formula-fed preterm infants < 2.5 kilograms result in improved growth and neurodevelopmental outcomes without evidence of short and long-term morbidity.

SEARCH STRATEGY

Two review authors searched MEDLINE (1966 - May 2005), CINAHL (1982 - May 2005), PubMed (1966 - May 2005), EMBASE (1980 - May 2005), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2005), abstracts, conferences and symposia proceedings from Society of Pediatric Research, and American Academy of Pediatrics. Cross references were reviewed independently for additional relevant titles and abstracts for articles up to fifty years old.

SELECTION CRITERIA

Randomized controlled trials contrasting levels of formula protein intakes as low (< 3.0 g/kg/day), high (=> 3.0 g/kg/day but < 4.0 g/kg/day), or very high protein intake (=> 4.0 g/kg/day) during hospitalization of neonates less than 2.5 kilograms at birth who were formula-fed. Studies were not included if infants received partial parenteral nutrition during the study period or were fed formula as a supplement to human milk. Given the small number of studies that met all inclusion criteria, studies in which nutrients other than protein also varied (> 10% relative difference) were added in a post-facto analysis.

DATA COLLECTION AND ANALYSIS

Two review authors used standard methods of the Cochrane Collaboration and of the Cochrane Neonatal Review Group to independently assess trial eligibility and quality, and extracted data. In a 3-arm trial where two groups fell within the same predesignated protein intake group, weighted means and pooled standard deviations were calculated.

MAIN RESULTS

The literature search identified 37 studies, of which five met all the inclusion criteria. All five studies compared low (< 3.0 g/kg/day) to high protein intakes (=> 3.0 g/kg/day but < 4.0 g/kg/day). The overall analysis revealed an improved weight gain (WMD 2.36 g/kg/day, 95% CI 1.31, 3.40) and higher nitrogen accretion (WMD 143.7 mg/kg/day, 95% CI 128.7, 158.8) in infants receiving formula with higher protein content while other nutrients were kept constant. None of the studies reported IQ or Bayley scores at 18 months or later. No significant differences were seen in rates of necrotizing enterocolitis, sepsis or diarrhea. Of three studies included in the post-facto analysis, only one could be included in the meta-analysis. The post-facto analysis revealed further improvement in all growth parameters in infants receiving formula with higher protein content (weight gain: WMD 2.53 g/kg/day, 95% CI 1.62, 3.45, linear growth: WMD 0.16 cm/week, 95% CI 0.03, 0.30, and head growth: WMD 0.23, 95% CI 0.12, 0.35). There was no significant difference (WMD 0.25, 95% CI -0.20, 0.70) in the concentration of plasma phenylalanine between the high and low protein intake groups. One study (Goldman 1969) in the post-facto analysis documented a significantly increased incidence of low IQ scores, below 90, in infants of birth weight less than 1300 grams who received a very high protein intake (6 to 7.2 g/kg/day).

AUTHORS' CONCLUSIONS

This systematic review suggests that higher protein intake (=> 3.0 g/kg/day but < 4.0 g/kg/day) from formula accelerates weight gain. Based on increased nitrogen accretion rates, this most likely indicates an increase in lean body mass. Although accelerated weight gain is considered to be a positive effect, increase in other outcome measures examined may represent a negative or ambivalent effect. These include elevated blood urea nitrogen levels and increased metabolic acidosis. Limited information was available regarding the impact of higher formula protein intakes on long term outcomes such as neurodevelopmental abnormalities. As determined in this review, existing research literature on this topic is not adequate to make specific recommendations regarding the provision of very high protein intake (> 4.0 g/kg/day) from formula.

Accuracy of methods for calculating postnatal growth velocity for extremely low birth weight infants

OBJECTIVE

No uniform method for calculating growth velocity (GV) (grams per kilogram per day) among extremely low birth weight (ELBW) infants has been reported. Because the calculation of actual GV is so labor intensive, investigators have estimated GV with varying approaches, making comparisons across studies difficult. This study compares the accuracy of 3 mathematical methods used for estimating average GV, namely, 2-point models using the difference between weights at 2 time points divided by time and weight (either birth weight [BW] or average weight), linear regression models that are normalized for either BW or average weight, and an exponential model. The accuracy of all models was compared with actual GVs calculated from daily weight measures for a group of ELBW infants.

METHODS

Actual GVs were calculated from daily weights for 83 ELBW infants admitted to the special care nursery and were compared with estimated GVs from each of the 5 models for the same infants.

RESULTS

The exponential model, using weights from 2 time points, ie, GV = [1000 x ln(Wn/W1)]/(Dn-D1), was extremely accurate, with mean absolute errors of 0.02% to 0.10%. The 2-point and linear models were highly inaccurate when BW was used in the denominator, with mean absolute errors of 50.3% to 96.4%. The 2-point and linear models were fairly accurate when average weight was used in the denominator, with mean absolute errors of 0.1% to 8.97%. Additional analyses showed that the accuracy of the 2-point and linear model estimates was affected significantly by the combination of BW, length of stay, and chronic lung disease, whereas the exponential model was not affected by these combined factors.

CONCLUSIONS

GV estimates calculated with 3 commonly used models varied widely, compared with actual GVs; however, the exponential model estimates were extremely accurate. The exponential model provides the accuracy and ease of use that are lacking in current methods applied to infant growth research.