Early versus later initiation of parenteral nutrition for very preterm infants: a propensity score-matched observational study

Neurodevelopment and the association with early life nutrition in moderate and late preterm infants

OBJECTIVES

Long-term neurodevelopment of moderate and late preterm infants (MLPTI; gestational age [GA] 32 0/7 weeks to 36 6/7 weeks) is at a lower level than that of those at term age. Increased protein and energy intakes in the first week of life have been associated with better neurodevelopment early in life, in very preterm infants. This study aimed to evaluate the neurodevelopmental outcome of MLPTI at 2 years corrected age (CA) for prematurity (i.e., after term equivalent age) and its association with nutritional intake in the first week of life.

METHODS

We prospectively collected nutritional data during the first week of life from 100 MLPTI (GA 32 0/7 weeks to 35 6/7 weeks). At 2 years CA, children underwent a neurodevelopmental assessment using the Bayley Scales of Infant and Toddler Development, Third edition, Dutch version (BSID-III-NL).

RESULTS

The mean BSID-III-NL (mean ± standard deviation [SD]) score was 103.1 (10.9) on the cognitive composite, 101.1 (SD ± 15.0) on the language composite, and 100.8 (SD ± 9.6) on the motor composite. Boys scored significantly lower than girls on both cognitive and language composite scores. We found no significant associations between nutritional intake in the first week of life and neurodevelopment at 2 years CA.

CONCLUSION

Neurodevelopment at 2 years CA was within normal limits, while boys scored lower than girls. First week nutritional intakes do not seem to be associated with neurodevelopmental outcomes at 2 years CA. This study emphasizes the need for more long-term follow-up and research concerning neurodevelopment in MLPTI, especially in boys.

Parenteral nutrition for preterm infants: benefits and risks in 2025

Parenteral nutrition (PN) has been a key component of neonatal care for preterm infants since the 1980's and provides macronutrients for growth, along with electrolytes, minerals, vitamins and trace elements. In this article we consider common issues with routine provision to very preterm infants including estimation of nutrient requirements, optimal starting doses of PN, rates of increase and maximum intakes. We consider monitoring strategies and outline common complications which may be serious and fatal. Finally, we consider risk-benefit ratios in different populations of preterm infants, and outline some of the major uncertainties in current practice.

Amino acids and protein for preterm infants: How much and for what?

Protein and amino acids derived from protein digestion in the gastrointestinal tract or from intravenous infusions are fundamental for normal metabolism, growth, and neurodevelopmental outcomes in the fetus and the preterm infant of the same gestational age. Many studies support that at least 3.0-3.5 g/kg/day of protein or amino acids are needed to achieve normal nitrogen/protein balance and growth rates and the large fractional increase of lean mass in later gestation, either in the fetus or the preterm infant; this relationship is direct and linear. Faster growth rates in earlier gestation require more amino acids and protein than the late preterm or term infant. Protein synthesis and accretion also require sufficient energy, but above ∼120 kcal/kg/day, energy is largely diverted to fat production but not lean mass growth. Optimal IV amino acid solutions remain to be developed, and mature maternal milk and donor human milk require protein supplements to achieve appropriate protein balance and growth. Additional supplements of growth factors might augment increased protein intakes and fortifiers. While excess amino acid and/or protein intakes do not promote growth or development and might even be harmful, providing less than the amounts required guarantees poorer outcomes and should be avoided.

AI-guided precision parenteral nutrition for neonatal intensive care units

One in ten neonates are admitted to neonatal intensive care units, highlighting the need for precise interventions. However, the application of artificial intelligence (AI) in guiding neonatal care remains underexplored. Total parenteral nutrition (TPN) is a life-saving treatment for preterm neonates; however, implementation of the therapy in its current form is subjective, error-prone and resource-consuming. Here, we developed TPN2.0-a data-driven approach that optimizes and standardizes TPN using information collected routinely in electronic health records. We assembled a decade of TPN compositions (79,790 orders; 5,913 patients) at Stanford to train TPN2.0. In addition to internal validation, we also validated our model in an external cohort (63,273 orders; 3,417 patients) from a second hospital. Our algorithm identified 15 TPN formulas that can enable a precision-medicine approach (Pearson's R = 0.94 compared to experts), increasing safety and potentially reducing cost. A blinded study (n = 192) revealed that physicians rated TPN2.0 higher than current best practice. In patients with high disagreement between the actual prescriptions and TPN2.0, standard prescriptions were associated with increased morbidities (for example, odds ratio = 3.33; P value = 0.0007 for necrotizing enterocolitis), while TPN2.0 recommendations were linked to reduced risk. Finally, we demonstrated that TPN2.0 employing a transformer architecture enabled guideline-adhering, physician-in-the-loop recommendations that allow collaboration between the care team and AI.

Outcomes following the adoption of standard parenteral nutrition in preterm infants: a whole-population non-concurrent control study

OBJECTIVE

To evaluate the impact of a quality improvement project of the adoption of standard parenteral nutrition (SPN) in preterm infants.

DESIGN

Retrospective, multicentre, whole-population, non-concurrent control study using data from the UK National Neonatal Research Database between 1 January 2014 and 31 December 2020.

SETTING

Neonatal units in London UK organised by geographical network.

PATIENTS

Preterm infants <31 weeks' gestation.

INTERVENTIONS

Introduction of two SPN formulations previously tested in randomised controlled trials (NEON and SCAMP). SCAMP delivers a higher target macronutrient intake.

MAIN OUTCOME MEASURES

The primary outcome was survival to discharge from neonatal care without major morbidities. Secondary outcomes included the individual components of the primary outcome and a comparison of outcomes between the NEON and the SCAMP formulations.

RESULTS

Of 6538 eligible infants, 4693 were admitted to neonatal care before and 1845 after the adoption of SPN. Morbidity-free survival decreased by an average of 8.6% (95% CI 5.8% to 11.4%, p<0.0001) following adoption. The effect varied by type of formulation; the cohort that adopted NEON showed no difference in morbidity-free survival, whereas the cohort that adopted SCAMP showed a statistically significant decrease in morbidity-free survival. Overall survival decreased by an average of 2.0% (95% CI 0.01% to 4.0%, p=0.048).

CONCLUSIONS

Research is urgently needed to identify the optimal composition of parenteral nutrition for preterm babies. This study also adds to the growing body of evidence that suggests that early and high intakes of macronutrients in preterm babies may be harmful.

Delayed Macronutrients' Target Achievement in Parenteral Nutrition Reduces the Risk of Hyperglycemia in Preterm Newborn: A Randomized Controlled Trial

Hyperglycemia (HG) is an independent risk factor of mortality and morbidity in very low birth weight newborns (VLBW). Achievement of high nutritional intakes in the first days of life (DoL) by parenteral nutrition (PN) increases the risk of HG. We aim to assess if a delayed achievement of the PN macronutrient target dose could reduce the occurrence of HG in VLBW. We enrolled 353 VLBW neonates in a randomized controlled clinical trial comparing two PN protocols that differed in the timing of energy and amino acid target dose achievement: (1) early target dose achievement (energy within 4-5 DoL; amino acids within 3-4 DoL) vs. (2) late target dose achievement (energy within 10-12 DoL; amino acids within 5-7 DoL). The primary outcome was the occurrence of HG during the first week of life. An additional endpoint was long-term body growth. We observed a significant difference in the rate of HG between the two groups (30.7% vs. 12.2%, p = 0.003). Significant differences were observed in terms of body growth at 12 months of life between the two groups (weight Z-Score: -0.86 vs. 0.22, p = 0.025; length: -1.29 vs. 0.55, p < 0.001). Delayed achievement of energy and amino acid intake may be useful to reduce the risk of HG along with an increase of growth parameters in VLBW neonates.

Use of parenteral nutrition in the first postnatal week in England and Wales: an observational study using real-world data

BACKGROUND

Parenteral nutrition (PN) is used to provide supplemental support to neonates while enteral feeding is being established. PN is a high-cost intervention with beneficial and harmful effects. Internationally, there is substantial variation in how PN is used, and there are limited contemporary data describing use across Great Britain.

OBJECTIVE

To describe PN use in the first postnatal week in infants born and admitted to neonatal care in England, Scotland and Wales.

METHOD

Data describing neonates admitted to National Health Service neonatal units between 1 January 2012 and 31 December 2017, extracted from routinely recorded data held the National Neonatal Research Database (NNRD); the denominator was live births, from Office for National Statistics.

RESULTS

Over the study period 62 145 neonates were given PN in the first postnatal week (1.4% of all live births); use was higher in more preterm neonates (76% of livebirths at <28 weeks, 0.2% of term livebirths) and in neonates with lower birth weight. 15% (9181/62145) of neonates given PN in the first postnatal week were born at term. There was geographic variation in PN administration: the proportion of live births given PN within neonatal regional networks ranged from 1.0% (95% CIs 1.0 to 1.0) to 2.8% (95% CI 2.7 to 2.9).

CONCLUSIONS AND RELEVANCE

Significant variation exists in neonatal PN use; it is unlikely this reflects optimal use of an expensive intervention. Research is needed to identify which babies will benefit most and which are at risk of harm from early PN.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT03767634; registration date: 6 December 2018.

Nutrition for the micro preemie: Beyond milk

Nutritional support is a fundamental component of the care of the extremely preterm infant, including the "micro preemie" (here defined as a baby born weighing less than 500 g), but goes beyond considerations of milk as a food. This is because milk from an infant's own mother, unlike currently available substitutes, additionally provides invaluable non-nutritive benefits. Nutritional support requires suitable devices or techniques to administer nutrients enterally or intravenously, products shown to be safe in preterm populations, and efficacy demonstrated in respect of important functional outcomes. Sadly, preterm feeding remains characterised by a deficit of evidence. In this chapter, we will briefly describe the history of preterm nutrition, discuss current enteral and parenteral practice, important evidence gaps, a summary of approaches for evaluating nutritional practice, and key considerations for future endeavour. Our discussion refers to all extremely preterm infants and it not confined to the micro preemie.