Expert consensus on clinical management of metabolic bone disease of prematurity (2021)

Analysis of clinical risk factors for metabolic bone disease of prematurity

Objective

To analyze clinical data related to preterm infants and identify risk factors for metabolic bone disease of prematurity (MBDP).

Methods

This study involved 856 newborns with a gestational age of less than 37 weeks or a weight of less than 1,500g at the Second Hospital of Jilin University. Multifactorial analysis was performed using logistic regression models to explore the risk factors for MBDP. Linear regression was used to investigate the factors affecting the time of alkaline phosphatase (ALP) exceedance and the peak value of ALP in the MBDP group.

Results

In the MBDP group, ALP excesses occurred in preterm infants at an average of 39.33 days after birth, and the mean value of peak ALP was 691.41 IU/L. Parenteral nutrition and the application of assisted ventilation were independent risk factors for MBDP, with ORs of 1.02 and 1.03 respectively. Gestational age was found to be a protective factor for earlier time of onset of ALP exceedance (β = 2.24,) and the increase in the peak value of ALP (β = -16.30).

Conclusion

Parenteral nutrition and the application of assisted ventilation are independent risk factors for MBDP. Gestational age is a major factor influencing the time of onset of ALP exceedance and the peak value of ALP in infants with MBDP.

Risk factors for severe bronchopulmonary dysplasia in a Chinese cohort of very preterm infants

OBJECTIVES

To examine the risk factors for severe bronchopulmonary dysplasia (BPD) in a cohort of very preterm infants (VPIs) in China, as BPD is common among VPIs and associated with a high mortality rate.

METHODS

In this multicenter retrospective study, medical records from infants with BPD born at gestation age (GA) of <32 weeks with birth weight (BW) of <1,500 grams (g) in 7 regions of China were included. The cohort was stratified into different BPD severity groups based on their fraction of inspired oxygen requirement at a modified GA of 36 weeks or post discharge. Risk factors were identified using logistic regression analysis.

RESULTS

A significant inverse correlation was revealed between BPD severity and both GA and BW (p<0.001). Independent risk factors for severe BPD (sBPD) were identified as invasive mechanical ventilation (≥7d), multiple blood transfusion (≥3), nosocomial infection (NI), hemodynamically significant patent ductus arteriosus (hsPDA), delayed initiation of enteral nutrition, and longer time to achieve total caloric intake of 110 kcal/kg. Conversely, administration of antenatal steroids was associated with reduced risk of sBPD.

CONCLUSION

Our study not only reaffirmed the established risk factors of low GA and BW for sBPD in VPIs, but also identified additional, potentially modifiable risk factors. Further research is warranted to explore whether intervention in these modifiable factors might reduce the risk of sBPD.Clinical Trial Reg. No.: ChiCTR1900023418.

Real-world evidence regarding the growth of very premature infants with small for gestational age after birth: a multicenter survey in China

BACKGROUND

To analyze the real-world growth pattern of very premature infants (VPI) with small for gestational age (SGA) after birth by using the ΔZ value of weight at discharge.

METHODS

The clinical data were collected from 28 hospitals in China from September 2019 to December 2020. They were divided into the EUGR(Extrauterine Growth Restriction) and the non-EUGR group according to the criterion of ΔZ value of weight at discharge < -1.28.

RESULTS

This study included 133 eligible VPI with SGA. Following the criterion of ΔZ value, the incidence of EUGR was 36.84% (49/133). The birth weight, the 5-min Apgar score, and the proportion of male infants in the EUGR group were lower (P < 0.05). The average invasive ventilation time, cumulative duration of the administration of antibiotics, blood transfusion time, blood transfusion ratio, and total days of hospitalization were significantly higher in the EUGR group (P < 0.05). In the EUGR group, several factors exhibited higher values (P < 0.05), including the initiation of enteral feeding, the volume of milk supplemented with human milk fortifier (HMF), the duration to achieve complete fortification, the cumulative duration of fasting, the duration to achieve full enteral feeding, the length of parenteral nutrition (PN), the number of days required to attain the desired total calorie intake and oral calorie intake, as well as the age at which birth weight was regained. The average weight growth velocity (GV) was significantly lower in the EUGR group (P < 0.001). The incidences of patent ductus arteriosus with hemodynamic changes (hsPDA), neonatal necrotizing enterocolitis (NEC) stage≥ 2, late-onset sepsis (LOS), and feeding intolerance (FI) in the EUGR group were higher (P < 0.05). Multivariate logistic regression analysis showed that birth weight, male, and GV were the protective factors, while a long time to achieve full-dose fortification, slow recovery of birth weight, and NEC stage ≥2 were the independent risk factors.

CONCLUSION

SGA in VPI can reflect the occurrence of EUGR more accurately by using the ΔZ value of weight at discharge. Enhancing enteral nutrition support, achieving prompt and complete fortification of breast milk, promoting greater GV, reducing the duration of birth weight recovery, and minimizing the risk of NEC can contribute to a decreased occurrence of EUGR.

TRIAL REGISTRATION

CHICTR, ChiCTR1900023418. Registered 26/05/2019, http://www.chictr.org.cn .

Establishment of a nomogram model for predicting metabolic bone disease in preterm infants: A case‒control study

OBJECTIVE

To investigate risk factors for metabolic bone disease (MBD) in preterm infants and establish a nomogram model for predicting MBD risk.

METHODS

A total of 1104 preterm infants were enrolled, among whom 809 were included in the modelling set and 295 were included in the validation set. The modelling set was divided into MBD (n = 185) and non-MBD (n = 624) groups. A multivariate logistic regression analysis was used to investigate the independent risk factors for MBD. R software was used to plot the nomogram model, which was then validated by the data of the validation set. Receiver operating characteristic (ROC) and calibration curves were used to evaluate the nomogram model's performance, and the clinical decision curve was used to assess the clinical practicability of the model.

RESULTS

Gestational age, time of trophic feeding initiation, parenteral nutrition duration, necrotizing enterocolitis, bronchopulmonary dysplasia, cholestasis and sepsis were independent risk factors for MBD in preterm infants (P < 0.05). The ROC curve of the modelling set had an area under the curve (AUC) of 0.801; the risk prediction value of 0.196 corresponding to the maximum Youden index was the best value, and the prediction critical value was 125 points. The ROC curve of the validation set had an AUC of 0.854. The calibration curve analysis showed good accuracy and consistency between the model's predicted and actual values.

CONCLUSIONS

The nomogram model provides an efficient tool for the early assessment of MBD risk. Preterm infants with scores ≥ 125 should receive close attention and interventions in the early stage.

WHAT IS KNOWN

• The incidence and severity of MBD are inversely proportional to gestational age and birth weight. Bone loss can lead to prolonged hospital stay, ventilator dependence, pathological fractures and short stature.

WHAT IS NEW

• Gestational age, time of trophic feeding initiation, parenteral nutrition duration, necrotizing enterocolitis, bronchopulmonary dysplasia, cholestasis and sepsis were independent risk factors for MBD in preterm infants. The nomogram model provides an efficient tool for the early assessment of MBD risk.

[Influencing factors for the development and severity of bronchopulmonary dysplasia in preterm infants with a gestational age of <32 weeks and a birth weight of <1 500 g]

OBJECTIVES

To study the influencing factors for the development and severity of bronchopulmonary dysplasia (BPD) in preterm infants with a gestational age of <32 weeks and a birth weight of <1 500 g.

METHODS

A retrospective analysis was performed on the medical data of preterm infants with a gestational age of <32 weeks and a birth weight of <1 500 g who were admitted to Women and Children's Hospital Affiliated to Xiamen University from January 1, 2017 to December 31, 2021. According to oxygen dependence on day 28 after birth, they were divided into two groups: BPD (n=218) and non-BPD (n=142). According to disease severity based on oxygen concentration required at the corrected age of 36 weeks or at discharge, the infants with BPD were divided into two groups: mild BPD (n=154) and moderate/severe BPD (n=64). Indices such as perinatal data and nutritional status were compared between groups. The multivariate logistic regression analysis was used to determine the influencing factors for BPD and its severity.

RESULTS

The incidence rate and severity of BPD increased with the reduction in gestational age and birth weight (P<0.05). The multivariate logistic regression analysis showed that a long duration of invasive mechanical ventilation (OR=1.320, P<0.05), hemodynamically significant patent ductus arteriosus (OR=2.032, P<0.05), and a prolonged time to reach oral calorie goal of 110 kcal/(kg·d) (OR=1.041, P<0.05) were risk factors for BPD, while an older gestational age was a protective factor against BPD (OR=0.535, P<0.05). Early-onset sepsis (OR=2.524, P<0.05) and a prolonged time to reach oral calorie goal of 110 kcal/(kg·d) (OR=1.029, P<0.05) were risk factors for moderate/severe BPD, while a high mean weight growth velocity was a protective factor against moderate/severe BPD (OR=0.906, P<0.05).

CONCLUSIONS

The incidence rate and severity of BPD in preterm infants with a gestational age of <32 weeks and a birth weight of <1 500 g can be reduced by shortening the duration of invasive mechanical ventilation, giving early treatment of early-onset sepsis and hemodynamically significant patent ductus arteriosus, adopting active enteral nutritional strategies, and increasing mean weight growth velocity.

Risk factors of extrauterine growth restriction in very preterm infants with bronchopulmonary dysplasia: a multi-center study in China

OBJECTIVE

Nutritional deficiency soon after birth is a risk factor of chronic lung disease (bronchopulmonary dysplasia, BPD). Afflicted infants are further prone to inadequate growth during hospitalization (extrauterine growth restriction, EUGR). This multi-center retrospective study investigated risk factors of EUGR, specifically in very preterm infants with BPD.

METHOD

Data of infants with BPD who were born less than 32 weeks gestation (n = 1010) were collected from 7 regions of China. All infants were non-small for gestational age at birth. Infants were characterized as EUGR or non-EUGR at 36 weeks gestation or discharge, or stratified by gestational age or birthweight. Logistic regression analysis was applied.

RESULTS

In 65.5% of the population, the BPD was mild. Infants with severe BPD (8.3%) had the highest rate of EUGR (72.6%, P < 0.001). Groups stratified by gestational age did not differ in rates of EUGR, but the birthweight of the EUGR group was significantly lower than that of the non-EUGR (P < 0.001). Birthweights of < 1000, 1000-1499, and ≥ 1500 g showed EUGR rates of 65.9%, 43.4%, and 23.8%, respectively (P < 0.001). Overall, the independent risk factors of EUGR were: moderate-to-severe BPD, gestational hypertension, cesarean section, cumulative fasting time, time required to achieve 110 kcal/kg/d, and hemodynamically significant patent ductus arteriosus (hsPDA).

CONCLUSION

In very preterm infants with BPD, the lower the birthweight or the more severe the BPD, the greater the risk of EUGR. In those with hsPDA, or moderate-to-severe BPD, it is especially important to prevent EUGR through perinatal management, enteral nutrition, and nutritional strategies.

[Evidence-based standardized nutrition protocol can shorten the time to full enteral feeding in very preterm/very low birth weight infants]

OBJECTIVES

To investigate whether evidence-based standardized nutrition protocol can facilitate the establishment of full enteral nutrition and its effect on short-term clinical outcomes in very preterm/very low birth weight infants.

METHODS

A retrospective analysis was performed on the medical data of 312 preterm infants with a gestational age of ≤32 weeks or a birth weight of <1 500 g. The standardized nutrition protocol for preterm infants was implemented in May 2020; 160 infants who were treated from May 1, 2019 to April 30, 2020 were enrolled as the control group, and 152 infants who were treated from June 1, 2020 to May 31, 2021 were enrolled as the test group. The two groups were compared in terms of the time to full enteral feeding, the time to the start of enteral feeding, duration of parenteral nutrition, the time to recovery to birth weight, the duration of central venous catheterization, and the incidence rates of common complications in preterm infants.

RESULTS

Compared with the control group, the test group had significantly shorter time to full enteral feeding, time to the start of enteral feeding, duration of parenteral nutrition, and duration of central venous catheterization and a significantly lower incidence rate of catheter-related bloodstream infection (P<0.05). There were no significant differences between the two groups in the mortality rate and the incidence rate of common complications in preterm infants including grade II-III necrotizing enterocolitis (P>0.05).

CONCLUSIONS

Implementation of the standardized nutrition protocol can facilitate the establishment of full enteral feeding, shorten the duration of parenteral nutrition, and reduce catheter-related bloodstream infection in very preterm/very low birth weight infants, without increasing the risk of necrotizing enterocolitis.

[Expert consensus on the follow-up management of bronchopulmonary dysplasia in preterm infants after discharge]

Bronchopulmonary dysplasia (BPD) is a common chronic lung disease in preterm infants and seriously affects the quality of life of preterm infants. BPD is a life-threatening disease to preterm infants and may lead to serious sequelae including feeding difficulties, recurrent lower respiratory tract infection, airway hyperreactive diseases, growth retardation, and neurodevelopmental delay. In order to further standardize the follow-up management of preterm infants with BPD after discharge, based on related clinical evidence in China and overseas and practice experience, the Neonatal Evidence-Based Medicine Group, Committee of Neonatal Medicine, Cross-Strait Medical and Health Exchange Association, formulated this expert consensus from the aspects of the follow-up and management of respiratory diseases, growth and development, pulmonary hypertension, nerve dysplasia, metabolic bone disease, and vaccination of preterm infants with BPD after discharge.

Human Milk Fortification in Very Preterm Infants in China: A Multicenter Survey

AIM

To investigate the use of human milk fortifier (HMF) for very preterm infants (VPIs) and complications and nutritional status of VPIs due to various breast milk enhancement strategies among the Chinese population.

METHODS

VPIs with birth weight < 1,800 g and wholly or predominantly breastfed were assigned to the following fortification groups: no HMF, early HMF (adding HMF at an enteral volume of ≤ 80 ml·kg^-1·day^-1), middle HMF (adding HMF at an enteral volume of 80-100 ml·kg^-1·day^-1), and late HMF (adding HMF at an enteral volume of ≥100 ml·kg^-1·day^-1). The growth status and complications for various groups were evaluated.

RESULTS

We enrolled 985 VPIs, of which 847 VPIs (86.0%) received HMF, whereas 138 VPIs (14.0%) did not. The number of VPIs in the early, middle, and late fortification groups were 89 (9.0%), 252 (25.6%), and 506 (51.4%), respectively. The complete fortification of the early, middle, and late fortification groups was achieved in 13.2 ± 11.0, 13.8 ± 11.7, and 12.3 ± 13.0 days, respectively, without significant differences (p > 0.05). The groups did not exhibit significant differences in the incidence of feeding intolerance, necrotizing enterocolitis (Bell stage ≥ 2), late-onset sepsis, and metabolic bone diseases (p > 0.05). The middle fortification groups exhibited the fastest growth velocity and the least dramatic decrease in the Z-score of weight and length, and the lowest incidence of EUGR (35.7%), whereas the "no HMF" groups exhibited the slowest growth velocity and the largest decline in the Z-score, and the highest incidence of EUGR (61.6%).

CONCLUSIONS

The usage rate of HMF was relatively low among Chinese VPIs, fortification often occurred in the late feeding stage, and the time to reach complete fortification was long. Adding HMF and different breast milk enhancement strategies did not increase the incidence of feeding intolerance and necrotizing enterocolitis. The enteral volume of 80-100 ml·kg^-1·day^-1 with HMF addition led to increased growth in the weight and length and lower EUGR incidence, indicating that the addition of HMF at the specific feeding volume might be the best practice for promoting growth.