ArticleLiterature Review

Nutritional support in the premature newborn

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Abstract

The theory and practice of nutritional support in the premature newborn has assumed increasing importance with survival of greater numbers of very immature infants. After birth, many do not tolerate full enteral feeding until gastrointestinal motor function has matured. During this process some will develop necrotising enterocolitis (NEC), a devastating failure of adaptation to postnatal life that may result in death, or severe complications. The feeding strategy that minimises the risk of NEC remains to be defined. In addition, promoting growth rates and nutrient accretion equivalent to those achieved during fetal development while optimising neurodevelopmental and long term health outcomes represents an important challenge for neonatologists. This review will focus on the problems associated with enteral nutrition, the requirement for parenteral nutrition, and the long term consequences of early nutritional interventions, underlining the need for prolonged follow up in assessing the potential benefits of different approaches to feeding.

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... and cholestasis [4 , 5] , and late re-feeding is associated with a prolonged hospital stay [6] . Conversely, premature reintroduction of enteral feeding in infants with NEC might induce disease progression [4] . Establishing a suitable biomarker to indicate which NEC infants are ready for the reintroduction of enteral feeding is therefore very relevant. ...
... We identified 120 preterm infants with suspected NEC who were eligible for inclusion, of whom 48 infants were diagnosed with proven NEC (Bell's stage ≥ 2) ( Fig. 1 and higher birth weight ( p = 0.02) than nonsurvivors. Fifteen infants (31%) needed surgical intervention on median day 2 [IQR [1][2][3][4][5]. Eleven infants (23%) did not survive. ...
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Background Levels of plasma citrulline (citrulline-P), a biomarker for enterocyte function, might be useful for the monitoring the course of necrotizing enterocolitis (NEC). Our aim was to evaluate whether citrulline-P levels during the first 48 h (h) after NEC onset were associated with need for surgery, survival, and intestinal recovery. Methods In preterm infants with NEC (Bell's stage ≥2) we measured citrulline-P levels during the first 48 h after NEC onset. Categorizing the measurements into 0–8 h, 8–16 h, 16–24 h, 24–36 h, and 36–48 h, we determined the course of citrulline-P using linear regression analyses. Next, we analyzed whether citrulline-P levels measured at 0–24 h and 24–48 h differed between conservative and surgical treatment, survivors and nonsurvivors, and equal/below and above total group's median time to full enteral feeding (FEFt). Results We included 48 infants, median gestational age 28.3 [IQR:26.0–31.4] weeks, birth weight 1200 [IQR:905–1524] grams. Citrulline-P levels decreased the first 48 h (B per time interval: -1.40 μmol, 95% CI, −2.73 to −0.07, p = 0.04). Citrulline-P was not associated with treatment, nor with survival. Citrulline-P at 0–24 h, but not 24–48 h, was higher in infants with FEFt ≤20 days than in infants with FEFt >20 days (20.7 [IQR:19.9–25.3] µmol/L (n = 13) vs. 11.1 [IQR:8.4–24.0] µmol/L (n = 11), p = 0.049), with a citrulline-P cut-off value of 12.3 μmol/L. Conclusion Citrulline-P levels decreased the first 48 h after NEC onset, suggesting on-going intestinal injury. In survivors, measuring citrulline-P in the first 24 h after NEC onset may provide an indication for intestinal recovery rate.
... 1 Rates of survival for preterm infants have dramatically increased over the last two decades. [2][3][4] In high-income settings, few infants born at less than 25 weeks of gestation were surviving in 1990; yet, by 2010 more than ...
... 3 The increased survival rates were likely due to improved neonatal care and early balanced feeding practices to sustain optimal growth. 2,5 These improvements include antenatal steroid exposure, 3,6,7 the widespread use of synthetic surfactant to treat severe respiratory distress syndrome, 8,9 high frequency ventilation, 3 and increased protein content as well as improved formulations of lipids in parenteral nutrition. 10 However, prematurity remains a public health priority as the single most important cause of death within the first month of life, and the second commonest cause of death before 5 years of age. ...
Article
Background The first report of children born very preterm (<32 weeks of gestation) having insulin resistance was made 16 years ago. However, neonatal care has improved since. Thus, we aimed to assess whether children born very preterm still have lower insulin sensitivity than term controls. Methods Participants were prepubertal children aged 5 to 11 years born very preterm (<32 weeks of gestation; n = 51; 61% boys) or at term (37‐41 weeks; n = 50; 62% boys). Frequently sampled intravenous glucose tolerance tests were performed, and insulin sensitivity was calculated using Bergman's minimal model. Additional clinical assessments included anthropometry, body composition using whole‐body dual‐energy X‐ray absorptiometry scans, clinic blood pressure, and 24‐hour ambulatory blood pressure monitoring. Results Children born very preterm were 0.69 standard deviation score (SDS) lighter (P < .001), 0.53 SDS shorter (P = .003), and had body mass index 0.57 SDS lower (P = .003) than children born at term. Notably, children born very preterm had insulin sensitivity that was 25% lower than term controls (9.4 vs 12.6 × 10⁻⁴ minutes⁻¹·[mU/L]; P = .001). Other parameters of glucose metabolism, including fasting insulin levels, were similar in the two groups. The awake systolic blood pressure (from 24‐hour monitoring) tended to be 3.1 mm Hg higher on average in children born very preterm (P = .054), while the clinic systolic blood pressure was 5.4 mm Hg higher (P = .002). Conclusions Lower insulin sensitivity remains a feature of children born very preterm, despite improvements in neonatal intensive care. As reported in our original study, our findings suggest the defect in insulin action in prepubertal children born very pretermis primarily peripheral and not hepatic.
... Lipid emulsions (based on soybean oil) frequently were started only after several days. (35) In the beginning of the 21 th century an evolution to a much more aggressive nutrition took place. (34,36,37) The gold standard for parenteral and enteral nutrition was to achieve, as soon as possible, nutritional intake taking as reference the in-utero placental nutrition. ...
... As compared with the 56-excluded formula-fed infants, the 33 infants who completed the study had significantly lower gestational age, lower prevalence of twins and stayed longer in the hospital (Table 3). Length of stay (days), mean (SD) 48 (18) Gestational age at discharge, median (IQR) 36 (35)(36)(37)(38)(39) IQR interquartile range; SD standard deviation; BW birth weight Table 3. Baseline characteristics of included versus excluded infants. Regarding the administered OMM, the measured true protein concentration decreased steeply from birth to the 10 th postnatal day, after which it gradually decreased and stabilized after the 36 th postnatal day (Figure 3). ...
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Background In very preterm infants, adequate early nutritional support is of utmost importance for the quality of growth and neurodevelopmental outcomes in the short-, medium- and long-term. Human milk (HM) has well-known advantages over infant formulas, including for brain development. Objectives To determine, in a homogeneous sample of HM-fed very preterm infants, the associations of in-hospital measured protein, energy, and protein-to-energy ratio (PER) intake with weight gain velocity, body composition and head circumference (HC) at term corrected age (CA), and with neurodevelopmental outcome at 18 months CA. Methods A cohort study was conducted, being eligible consecutive inborn neonates with less than 33 weeks of gestation, who were exclusively or predominantly HM-fed (own’s mother milk and/or donor human milk). The study was approved by the Hospital and Medical School ethics committees and is registered at the ISRCTN (ID: 27916681). Informed written consent was obtained from the parents or legal representative of each infant. Our unit nutrition protocol, based on international and national recommendations, was followed. A standard fortification method with the blinded addition of modular protein and/or fat supplements was used, considering the lowest reported HM protein content and the minimum recommended intake for weight. A mid-infrared analyzer was used to measure the macronutrients content of administered HM. Anthropometry was performed using the recommended techniques. Body composition assessment, using air displacement plethysmography (ADP), was scheduled after discharge, at 40 weeks CA; fat mass percentage (FM%) and fat mass index (FMI) were used as surrogates of adiposity. The assessment of the Mental Developmental Index (MDI) and Psychomotor xviii Developmental Index (PDI), using the Bayley Infant Development Scales version II, were scheduled at 18 months CA. Statistical analysis: required samples of 70 and 75 infants were estimated to detect significant differences in body composition and neurodevelopmental outcomes, respectively. Univariate analysis, using parametric or nonparametric tests as adequate, assessed the associations of cumulative in-hospital protein, energy, and PER intake with weight gain velocity, fat mass (FM), fat-free mass (FFM), FM%, FMI, HC, MDI, and PDI. The same statistical methods were used to assess potential confounding variables, using p<0.10 for inclusion in models. Linear mixed models were used to input missing measured values of own’s mother milk composition and linear multiple regression analyses were used to assess the adjusted effect between independent and dependent variables. A nested case-control analysis was used to determine the associations of lower (≤ -1 z-score) and higher (≥ +1 z-score) adiposity with protein, energy, and PER intake. Results Thirty-three infants were included in the cohort, with a median (interquartile range) gestational age of 30 (28-31) weeks and birthweight of 1175 (1010-1408) g. Compared with the 56-excluded formula-fed infants, the 33 infants who completed the study had significantly lower gestational age, lower prevalence of twins and stayed longer in hospital. Eight hundred and thirty-two pooled HM samples were analyzed, representing 65.0% of the total administered samples. After disclosing the HM macronutrients measurements, it was found that the minimum recommended intake for weight were achieved in 63.6% of infants for protein, 15.2% for energy, and 93.9% for PER. The median daily protein, energy, and PER intake from birth to 35 weeks CA ranged from 2.7-4.2 g/kg, 53.7-109.2 kcal/kg, and 3.4-5.6, respectively. The mean (standard deviation - SD) in-hospital weight gain velocity was 10.1 (3.8) g/kg/day. At mean (SD) 39.9 (1.9) weeks, body mass was of 2817.6 (504.3) g, FM of 441.5 (184.0) g, FFM of 2376.1 (376.0) g, FM% of 15.3 (4.8), and FMI of 2.0 (0.7). xix Neurodevelopment was assessed at 20 months CA. Overall, the mean (SD) score for MDI was 100.2 (11.5) and for PDI 97.4 (8.0). The mean MDI score was below normal in 6.2% infants, normal in 78.1%, and accelerated in 15.6%; the mean PDI score was below normal in 6.2% infants and normal in 93.8%. In multivariate analysis, only gestational age was associated with low weight gain velocity (p<0.0001). After adjustment for gestational age, only FFM was associated with low protein (p=0.008) and energy (p=0.001) intake. In the nested case-control analysis, in infants with lower adiposity, a FM% ≤ -1 z-score was associated with low energy and protein intake (p=0.050) and a FMI ≤ -1 z-score was associated with low PER intake (p=0.026); in infants with higher adiposity, a FMI ≥ +1 z-score was associated with low energy intake (p<0.0001) and high PER intake (p<0.0001). In multivariate analysis, it was found that GA and sex were predictors of high HC at term CA, adjusted for protein (p=0.010), energy (p=0.013) and PER intake (p=0.013). In-hospital cumulative protein, energy, and PER intake were neither significantly correlated with any MDI or PDI scores at mean 20 months CA, nor met the defined criteria to enter multivariate analysis. Conclusions In this cohort of exclusively or almost exclusively HM-fed very preterm infants, the cumulative in-hospital protein, energy, and PER intake were weakly-to-moderately correlated with weight gain velocity, but not with body composition at term CA in the entire sample. Analyzing infants with extremes of adiposity, those with lower adiposity received significantly lower energy, protein, and PER intake, while infants with higher adiposity received significantly lower energy intake but higher PER intake, compared with the remaining infants. The GA and sex were significant predictors of high HC at term CA, adjusted for protein, energy and PER intake. In-hospital cumulative protein, energy, and PER intake were not significantly correlated with MDI or PDI scores at a mean of 20 months CA. The method of standard fortification with blinded modular protein and fat supplements resulted in insufficient energy and protein intake. The undersized sample might be insufficient to test the hypothesized associations of macronutrient intake with body composition and neurodevelopmental outcome. xx Notwithstanding, our analyses have relied on measured protein and energy HM content and not on its assumed composition, which is a strength of the study. Key-words: body composition, energy intake, head circumference, human milk, neurodevelopmental outcome, protein intake, very preterm infants, weight gain velocity.
... During the first 6 months of life, the extent of growth is explained by size at birth. 7,8 Preterm infants are commonly at higher risk of short stature. Approximately 50% of children who fail to grow by the age of two retain short stature in adulthood. ...
... Approximately 50% of children who fail to grow by the age of two retain short stature in adulthood. 6,7,24,25 The availability of growth curves adapted to our population would contribute to better nutritional diagnoses. For this study, we had to consider the Fenton charts, 18 which are designed for preterm infants, and then make the necessary adjustments for applying the WHO curves. ...
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Morbidity and mortality rates are higher among preterm infants due to physiological immaturity and greater growth demands. Nutritional intervention contributes to proper weight gain, which translates into better growth and neurological development, and prevents the onset of metabolic complications. The effect of breastfeeding duration was studied in the analytic profile at the end of the first six months of life. To describe the nutritional and metabolic markers effect in preterm infants at the end of the first semester of life. We performed an analytical, transversal and comparative study in 100 preterm infants, 30 to 36 weeks gestational age. Measures for weight, length and head circumference at birth were taken from the subjects' clinical files. A follow-up conducted at 6 to 9 months of age evaluated the same nutritional indicators (weight, length, head circumference) and compared them with values at birth and recommendations. Metabolic indicators (glucose, hemoglobin, cholesterol, triglycerides, insulin, urea, creatinine, gamma-glutamyl-transferase and alkaline phosphatase) were compared with the recommendations. Follow-up study in 100 preterm infants (30 to 36 weeks gestational age). Weight, length and head circumference were measured at birth and 6 to 9 months later. We measured analytic parameters related to metabolic syndrome (glucose, hemoglobin, cholesterol, triglycerides, insulin, urea, creatinine, gamma-glutamyl transferase and alkaline phosphatase). Confusing factors like income level and access to public services were also studied. The mean age at follow-up was 7.3 +/- 1.4 months. Levels of hemoglobin, creatinine and urea showed significant differences with regard to reference values (Wilcoxon ranks test, < 0.05). The average duration of breastfeeding was 4.3 months. The mean age at follow-up was 7.3 +/- 1.4 months. Risk factors for hypercholesterolemia, as well as levels of hemoglobin, creatinine and urea showed significant differences with regard to reference values (Wilcoxon ranks test, < 0.05). Premature infants showed deficiencies in weight gain. Biochemical parameters could reflect metabolic risk, therefore we recommend prolonging breastfeeding as well as extending the follow-up of these infants for monitoring their growth and development once out of the hospital.
... Consequently, meeting these requirements is a considerable challenge, with effects on morbidity and mortality in early infancy. Historically, the goal has been to replicate in utero growth, but this objective is rarely achieved (63) . Initially, parenteral nutrition with minimal enteral feeding is advocated in these high-risk infants (63) . ...
... Historically, the goal has been to replicate in utero growth, but this objective is rarely achieved (63) . Initially, parenteral nutrition with minimal enteral feeding is advocated in these high-risk infants (63) . Enteral feeding with human breast milk, which dramatically reduces the risk of necrotising enterocolitis, is particularly relevant to premature newborns. ...
Article
Nutrition in early life, a critical period for human development, can have long-term effects on health in adulthood. Supporting evidence comes from epidemiological studies, animal models and experimental interventions in human subjects. The mechanism is proposed to operate through nutritional influences on growth. Substantial evidence now supports the hypothesis that 'accelerated' or too fast infant growth increases the propensity to the major components of the metabolic syndrome (glucose intolerance, obesity, raised blood pressure and dyslipidaemia), the clustering of risk factors that predispose to cardiovascular morbidity and mortality. The association between infant growth and these risk factors is strong, consistent, shows a dose-response effect and is biologically plausible. Moreover, experimental data from prospective randomised controlled trials strongly support a causal link between infant growth and later risk factors for atherosclerosis. Evidence that infant growth affects the development of atherosclerosis therefore suggests that the primary prevention of CVD should begin from as early as the first few months of life. The present review considers this evidence, the underlying mechanisms involved and its implications for public health.
... It is unknown whether the absolute amount of lipids administered, elevations in certain fatty acids within the externally administered triglycerides, or levels of lipoprotein lipase alone are responsible for the development of hypertriglyceridemia or if it is a combination of these factors. Maintaining nutritional support that allows for appropriate growth and metabolism while avoiding feeding-related side effects such as hypertriglyceridemia remains a daunting challenge for neonatologists [7]. ...
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Background In preterm infants, IV administration of fat is less well tolerated compared to intake via the enteral route, often resulting in hypertriglyceridemia. It is therefore recommended that parenteral fat intake should not exceed 3.5 to 4.0 g/kg/d whereas human milk can provide up to 8 g/kg/d. It is unknown whether such hypertriglyceridemic conditions are caused by a uniform increase of all fatty acids or it is linked to an elevation of distinct fatty acids due to an unbalanced intake. Obviously, both scenarios could potentially influence the formulation of novel lipid solutions for preterm infants. Objective of this exploratory study was to compare fatty acid profiles between a) different nutritional sources and corresponding plasma samples, b) plasma of infants fed breast milk versus those receiving lipid emulsion, and c) plasma of infants with normal versus elevated triglyceride levels. Methods Forty-seven preterm infants < 36 weeks of gestation were included; fatty acid profiles were measured in serum samples and corresponding nutritional sources (breast milk and lipid emulsion) using gas chromatography/mass spectrometry. Results Compared to breast milk levels, plasma contained significantly lower C8:0, C10:0, C12:0, C14:0, C19:1n9, C18:3n3 (p < 0.0001). In contrast, relative abundance of C16:0, C18:0 and C20:4n6 was higher in plasma than in corresponding breast milk samples (p < 0.001) and lipid emulsion (p < 0.01). Compared to the corresponding lipid emulsion, the abundance of C18:2n6 and C18:3n3 was significantly lower in plasma (p < 0.001). Fatty acid profiles in plasma of infants fed breast milk compared to lipid emulsion were not markedly different. Hypertriglyceridemic samples showed elevated levels for C18:1n9 and C16:0 when compared with normotriglyceridemic samples. Conclusions Our study reveals that lipid levels in plasma show both depletion and enrichment of distinct fatty acids which do not seem to be closely related to dietary intake. A more detailed understanding of fatty acid flux rates is needed, like the understanding of amino acid metabolism and is supported by the finding that hypertriglyceridemia might be a state of selective fatty acid accumulation. This would allow to develop more balanced diets for intensive care and potentially improve clinical outcomes.
... Even with normal treatments, preterm infants may not always reach their full developmental potential. Postnatal growth restriction cannot be avoided by the dietary approaches now used to treat intrauterine growth restriction (IUGR) and preterm neonates [72]. For preterm live birth (LBW) children, extrauterine growth restriction, or EUGR, is a serious issue; the incidences for head circumference, weight, and length are around 28, 34, and 16%, respectively [73]. ...
Article
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Premature infants have less nutritional storage capacity and an underdeveloped body, which makes them particularly susceptible to malnutrition. Nutrient surplus and deficiency are possibilities when supplemental feeding is unbalanced. However, little is known about what kids should eat once they are discharged from the hospital. Since many bodily processes depend on micronutrients, it's critical to plan supplemental nutrition with an optimum consumption in mind. This written summary describes the requirements for long-chain polyunsaturated fatty acids (LCPUFA), iron, zinc, vitamin D, calcium, and phosphate for premature newborns receiving supplemental feeding. The scientific community is beginning to acknowledge the advantages of giving premature babies iron and vitamin D supplements. But as of right now, there isn't enough information available to make firm recommendations about the addition of calcium, phosphorus, zinc, and LCPUFAs. Nonetheless, the health of premature infants depends on the following micronutrients: Large chain polyunsaturated fats (LCPUFAs) support the development of the retina and brain, while calcium and phosphorus dosages are necessary to prevent metabolic bone disease (MBD) in preterm infants. It is obvious how understanding the variability of the premature population may help adapt nutritional planning in connection to the development rate, comorbidities, and thorough clinical history of the preterm newborn, even while we wait for consensus on these micronutrients.
... Despite following standard practices, the growth in preterm infants may not be optimal in most cases. Current nutritional strategies or practices being followed for intrauterine growth restriction (IUGR)/preterm infants are not able to prevent postnatal growth restriction (49). Extrauterine growth restriction (EUGR) is a serious issue in preterm LBW infants, with an incidence of about 28, 34, and 16% for weight, length, and head circumference, respectively (50). ...
... The development of preterm neonates may not always go as planned, even when standard protocols are followed. The dietary strategies now employed to treat intrauterine growth restriction (IUGR)/preterm newborns cannot prevent postnatal growth restriction [72]. Extrauterine growth restriction (EUGR) is a significant problem in premature LBW newborns, with incidence rates for head circumference, weight, and length of around 28, 34, and 16%, respectively [73]. ...
... Current treatments consist of magnesium sulfate administration [127], caffeine for treatment of apnoea, and high doses of DHA [128]. To avoid complications in premature infants, different nutritional supports are used, such as enteral or parenteral nutrition, human breast milk, and formula milk [129]. Enteral nutrition is limited in preterm birth because of the immature gastrointestinal motor activity and risks of necrotizing enterocolitis [130]. ...
Article
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n-3 and n-6 polyunsaturated fatty acids (PUFAs) are essential fatty acids that are provided by dietary intake. Growing evidence suggests that n-3 and n-6 PUFAs are paramount for brain functions. They constitute crucial elements of cellular membranes, especially in the brain. They are the precursors of several metabolites with different effects on inflammation and neuron outgrowth. Overall, long-chain PUFAs accumulate in the offspring brain during the embryonic and post-natal periods. In this review, we discuss how they accumulate in the developing brain, considering the maternal dietary supply, the polymorphisms of genes involved in their metabolism, and the differences linked to gender. We also report the mechanisms linking their bioavailability in the developing brain, their transfer from the mother to the embryo through the placenta, and their role in brain development. In addition, data on the potential role of altered bioavailability of long-chain n-3 PUFAs in the etiologies of neurodevelopmental diseases, such as autism, attention deficit and hy-peractivity disorder, and schizophrenia, are reviewed.
... Since the GI tract is still premature to take up its role, parenteral feeding is usually unavoidable. These issues arise predominantly when birth weight is less than 1.500 kg or the age is lower than 34 weeks [11]. In this cases, TPN is usually applied if it is anticipated that enteral feeding will not be achieved for at least two days [6][7][8]. ...
Article
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Total parenteral nutrition is a feeding strategy widely used in children and, particularly, in preterm infants, due to a variety of pathological conditions that hinder enteral feeding. Parenteral feeding has been associated with the development of metabolic bone diseases. These can manifest as rickets and/or pediatric osteopo-rosis, with a prevalence reaching 40%, while the nutritional limitations of parenteral feeding, along with the increased metabolic needs of the bones at this growth stage, further deteriorate the problem. There are plenty of theories regarding the underlying mechanisms. Deficiency or toxicity of nutrients, such as calcium, phosphorus and vitamin D, and cholestasis have been identified as risk factors. Another contributing factor is the contamination with aluminum, with its numerous deleterious effects, along with the composition of the fatty acid emulsions administered. Appropriate enrichment of parenteral nutrition solutions with specific nutrients plays a key role in managing or preventing the disease. High standards in the use of this method, including the restriction of aluminum contamination, are of high importance. The role of clinicians and nurses is crucial, since a significant level of alert for malnutrition signs is required, as well as high professional standards for applying and maintaining the parenteral nutrition setting.
... Energy and protein are the two important factors that affect growth, thus, one of the key goals of nutrition management is to facilitate their absorption. 3 The newborn infants not received any protein will have a negative nitrogen balance and lose up to 1% of their protein reserves every day. 4 In addition, recent studies report that insulin levels drop when there is amino acid deficiency, leading to hyperglycemia and hyperkalemia. ...
Article
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Very Low Birth Weight (VLBW) infants have higher nutritional needs than term infants. Energy and protein are two important factors influencing their growth. Breastfeeding is not enough to meet VLBW infants’ needs, for this reason, complementary protein is required by them. Hence, the present study aimed at investigation of renal function among VLBW infants receiving complementary proteins. The study was conducted on two groups of intervention and control (n= 18 in each group) (Case study: VLBW infants born in Akbarabadi hospital of Tehran in 2014 2015). The intervention group includes 3-year-old children who weighting less than 1200 grams at birth and have received protein supplementation at the course of NICU hospitalization, protein was added to maternal milk when the amount of milk reaches to 100 cc/kg/day, at this time parenteral nutrition was discontinued and the volume of feeding was increased 20cc/kg/day until reached to 150-180cc/kg/day. We also added the fortifier to breast milk at this time. The fortification and the protein supplementation were stopped when the weight of the baby reached to 1500 grams. The control group was fed similar to the intervention group but had received no complementary protein . The renal function was evaluated by measuring such criteria as BUN, Cr, ALB and U/A. After data collection, a statistical analysis was performed using SPSS software Ver. 22. Following to BUN evaluation, a significant correlation was seen between BUN and received protein (p-value=0.010). However, there was no significant correlation between Cr and received protein as well as mean values of the two groups (p-value=0.0766). Similarly, an insignificant correlation was found between the two groups following to investigation of ALB (p-value=0/257), while the mean values of the two groups were similar. The both groups were also equal in U/A. The complementary protein increased the BUN with no effect on Cr, ALB and U/A, providing no impact on renal function. Therefore, complementary protein intake made no conflict in renal function.
... It must be taken into account that a long duration of PN can lead to complications, mainly infections [40] or metabolic complications (hyperlipidaemias, hyperbilirubinaemia, cholestasis) [41]. Therefore, PN should be terminated when it is possible to orally administer a sufficient amount of enteral nutrition (EN) to satisfy the minimum nutritional requirements equivalent to those achieved during foetal development [42]. In this study, data on EN prescriptions could not be collected; however, as expected, longer duration of PN was associated with lower GA and lower BW. ...
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Background: In preterm infants, it is important to ensure adequate nutritional intake to accomplish foetal growth requirements. This study evaluated clinical practice regarding the prescription of parenteral nutrition in preterm infants in the neonatology unit of a tertiary hospital. Methods: It was a retrospective observational study of a sample of preterm infants (n = 155) born between January 2015 and December 2017 who were prescribed parenteral nutrition. Compliance with the hospital's protocol and with the guidelines of the scientific societies American Society for Parenteral and Enteral Nutrition (ASPEN), European Society for Clinical Nutrition and Metabolism (ESPEN) and Spanish Society of Clinical Nutrition and Metabolism (SENPE) was evaluated. The differences in macronutrient intake and total duration of parenteral nutrition were analysed according to gestational age and birth weight. Results: The established protocol was followed in a high percentage (95.5%-100%) except with respect to the initiation of supplying established trace elements (64.9%). Compliance with the recommendations set forth in the guidelines was between 82.1% and 100%, with the exception of the initial carbohydrate intake recommended by ASPEN and ESPEN, for which compliance was 8.3%. Lower gestational age and birth weight were correlated with longer duration of parenteral nutrition (p < 0.001). Conclusions: A lower gestational age and birth weight are related to a longer duration of parenteral nutrition. The results of this study demonstrate the importance of developing and evaluating protocols in clinical practice.
... The daily intake is increased several days after birth to reach the ideal volume of 200 ml/ kg of breast milk and 150 ml/ kg of Pre Nan milk [3]. Many physicians do not recommend starting enteral nutrition until maturation of gastrointestinal motor function [9]. If the premature baby is unable to take nutrients orally, it will be compensated by Parenteral feeding, through which the foods made up of amino acids, fatty acids, vitamins, ...
... Energy and protein are the two important factors that affect growth, thus, one of the key goals of nutrition management is to facilitate their absorption. 3 The newborn infants not received any protein will have a negative nitrogen balance and lose up to 1% of their protein reserves every day. 4 In addition, recent studies report that insulin levels drop when there is amino acid deficiency, leading to hyperglycemia and hyperkalemia. ...
Article
Full-text available
Very Low Birth Weight (VLBW) infants have higher nutritional needs than term infants. Energy and protein are two important factors influencing their growth. Breastfeeding is not enough to meet VLBW infants’ needs, for this reason, complementary protein is required by them. Hence, the present study aimed at investigation of renal function among VLBW infants receiving complementary proteins. The study was conducted on two groups of intervention and control (n= 18 in each group) (Case study: VLBW infants born in Akbarabadi hospital of Tehran in 2014 2015). The intervention group includes 3-year-old children who weighting less than 1200 grams at birth and have received protein supplementation at the course of NICU hospitalization, protein was added to maternal milk when the amount of milk reaches to 100 cc/kg/day, at this time parenteral nutrition was discontinued and the volume of feeding was increased 20cc/kg/day until reached to 150-180cc/kg/day. We also added the fortifier to breast milk at this time. The fortification and the protein supplementation were stopped when the weight of the baby reached to 1500 grams. The control group was fed similar to the intervention group but had received no complementary protein . The renal function was evaluated by measuring such criteria as BUN, Cr, ALB and U/A. After data collection, a statistical analysis was performed using SPSS software Ver. 22. Following to BUN evaluation, a significant correlation was seen between BUN and received protein (p-value=0.010). However, there was no significant correlation between Cr and received protein as well as mean values of the two groups (p-value=0.0766). Similarly, an insignificant correlation was found between the two groups following to investigation of ALB (p-value=0/257), while the mean values of the two groups were similar. The both groups were also equal in U/A. The complementary protein increased the BUN with no effect on Cr, ALB and U/A, providing no impact on renal function. Therefore, complementary protein intake made no conflict in renal function.
... 1 However, very preterm neonates (VPNs) are unable to tolerate and obtain sufficient feeds to meet nutritional needs due to transient gut immaturity 2 and immature gastrointestinal motor function. 3 This usually occurs in the first few weeks of life, and during this time, VPNs are totally or partially dependent on parenteral nutrition (PN). [4][5][6] The aims of PN supply are to ensure provision of sufficient energy not only to meet nutritional requirements but also for growth and neurodevelopment. ...
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Context: Very preterm neonates (VPNs) are unable to digest breast milk and therefore rely on parenteral nutrition (PN) formulations. This systematic review was prepared following PRISMA-P 2015 guidelines. For the purpose of this review, desirable mean plasma arginine concentration is defined as ≥80 micromoles/L. Objective: The review was performed to answer the following research question: "In VPNs, are high amounts of arginine in PN, compared with low amounts of arginine, associated with appropriate circulating concentrations of arginine?" Therefore, the aims were to 1) quantify the relationship between parenteral arginine intakes and plasma arginine concentrations in PN-dependent VPNs; 2) identify any features of study design that affect this relationship; and 3) estimate the target parenteral arginine dose to achieve desirable preterm plasma arginine concentrations. Data sources: The PubMed, Scopus, Web of Science, and Cochrane databases were searched regardless of study design; review articles were not included. Data extraction: Only articles that discussed amino acid (AA) intake and measured plasma AA profile post PN in VPNs were included. Data were obtained using a data extraction checklist that was devised for the purpose of this review. Data analysis: Twelve articles met the inclusion criteria. The dose-concentration relationship of arginine content (%) and absolute arginine intake (mg/(kg × d)) with plasma arginine concentrations showed a significant positive correlation (P < 0.001). Conclusion: Future studies using AA solutions with arginine content of 17%-20% and protein intakes of 3.5-4.0 g/kg per day may be needed to achieve higher plasma arginine concentrations.
... Length of stay (days), mean (SD) 48 (18) Gestational age at discharge, median (IQR) 36 (35)(36)(37)(38)(39) IQR interquartile range; SD standard deviation; BW birth weight Table 3. Baseline characteristics of included versus excluded infants. Regarding the administered OMM, the measured true protein concentration decreased steeply from birth to the 10 th postnatal day, after which it gradually decreased and stabilized after the 36 th postnatal day (Figure 3). ...
Thesis
Background In very preterm infants, adequate early nutritional support is of utmost importance for the quality of growth and neurodevelopmental outcomes in the short-, medium- and long-term. Human milk (HM) has well-known advantages over infant formulas, including for brain development. Objectives To determine, in a homogeneous sample of HM-fed very preterm infants, the associations of in-hospital measured protein, energy, and protein-to-energy ratio (PER) intake with weight gain velocity, body composition and head circumference (HC) at term corrected age (CA), and with neurodevelopmental outcome at 18 months CA. Methods A cohort study was conducted, being eligible consecutive inborn neonates with less than 33 weeks of gestation, who were exclusively or predominantly HM-fed (own’s mother milk and/or donor human milk). The study was approved by the Hospital and Medical School ethics committees and is registered at the ISRCTN (ID: 27916681). Informed written consent was obtained from the parents or legal representative of each infant. Our unit nutrition protocol, based on international and national recommendations, was followed. A standard fortification method with the blinded addition of modular protein and/or fat supplements was used, considering the lowest reported HM protein content and the minimum recommended intake for weight. A mid-infrared analyzer was used to measure the macronutrients content of administered HM. Anthropometry was performed using the recommended techniques. Body composition assessment, using air displacement plethysmography (ADP), was scheduled after discharge, at 40 weeks CA; fat mass percentage (FM%) and fat mass index (FMI) were used as surrogates of adiposity. The assessment of the Mental Developmental Index (MDI) and Psychomotor xviii Developmental Index (PDI), using the Bayley Infant Development Scales version II, were scheduled at 18 months CA. Statistical analysis: required samples of 70 and 75 infants were estimated to detect significant differences in body composition and neurodevelopmental outcomes, respectively. Univariate analysis, using parametric or nonparametric tests as adequate, assessed the associations of cumulative in-hospital protein, energy, and PER intake with weight gain velocity, fat mass (FM), fat-free mass (FFM), FM%, FMI, HC, MDI, and PDI. The same statistical methods were used to assess potential confounding variables, using p<0.10 for inclusion in models. Linear mixed models were used to input missing measured values of own’s mother milk composition and linear multiple regression analyses were used to assess the adjusted effect between independent and dependent variables. A nested case-control analysis was used to determine the associations of lower (≤ -1 z-score) and higher (≥ +1 z-score) adiposity with protein, energy, and PER intake. Results Thirty-three infants were included in the cohort, with a median (interquartile range) gestational age of 30 (28-31) weeks and birthweight of 1175 (1010-1408) g. Compared with the 56-excluded formula-fed infants, the 33 infants who completed the study had significantly lower gestational age, lower prevalence of twins and stayed longer in hospital. Eight hundred and thirty-two pooled HM samples were analyzed, representing 65.0% of the total administered samples. After disclosing the HM macronutrients measurements, it was found that the minimum recommended intake for weight were achieved in 63.6% of infants for protein, 15.2% for energy, and 93.9% for PER. The median daily protein, energy, and PER intake from birth to 35 weeks CA ranged from 2.7-4.2 g/kg, 53.7-109.2 kcal/kg, and 3.4-5.6, respectively. The mean (standard deviation - SD) in-hospital weight gain velocity was 10.1 (3.8) g/kg/day. At mean (SD) 39.9 (1.9) weeks, body mass was of 2817.6 (504.3) g, FM of 441.5 (184.0) g, FFM of 2376.1 (376.0) g, FM% of 15.3 (4.8), and FMI of 2.0 (0.7). xix Neurodevelopment was assessed at 20 months CA. Overall, the mean (SD) score for MDI was 100.2 (11.5) and for PDI 97.4 (8.0). The mean MDI score was below normal in 6.2% infants, normal in 78.1%, and accelerated in 15.6%; the mean PDI score was below normal in 6.2% infants and normal in 93.8%. In multivariate analysis, only gestational age was associated with low weight gain velocity (p<0.0001). After adjustment for gestational age, only FFM was associated with low protein (p=0.008) and energy (p=0.001) intake. In the nested case-control analysis, in infants with lower adiposity, a FM% ≤ -1 z-score was associated with low energy and protein intake (p=0.050) and a FMI ≤ -1 z-score was associated with low PER intake (p=0.026); in infants with higher adiposity, a FMI ≥ +1 z-score was associated with low energy intake (p<0.0001) and high PER intake (p<0.0001). In multivariate analysis, it was found that GA and sex were predictors of high HC at term CA, adjusted for protein (p=0.010), energy (p=0.013) and PER intake (p=0.013). In-hospital cumulative protein, energy, and PER intake were neither significantly correlated with any MDI or PDI scores at mean 20 months CA, nor met the defined criteria to enter multivariate analysis. Conclusions In this cohort of exclusively or almost exclusively HM-fed very preterm infants, the cumulative in-hospital protein, energy, and PER intake were weakly-to-moderately correlated with weight gain velocity, but not with body composition at term CA in the entire sample. Analyzing infants with extremes of adiposity, those with lower adiposity received significantly lower energy, protein, and PER intake, while infants with higher adiposity received significantly lower energy intake but higher PER intake, compared with the remaining infants. The GA and sex were significant predictors of high HC at term CA, adjusted for protein, energy and PER intake. In-hospital cumulative protein, energy, and PER intake were not significantly correlated with MDI or PDI scores at a mean of 20 months CA. The method of standard fortification with blinded modular protein and fat supplements resulted in insufficient energy and protein intake. The undersized sample might be insufficient to test the hypothesized associations of macronutrient intake with body composition and neurodevelopmental outcome. xx Notwithstanding, our analyses have relied on measured protein and energy HM content and not on its assumed composition, which is a strength of the study. Key-words: body composition, energy intake, head circumference, human milk, neurodevelopmental outcome, protein intake, very preterm infants, weight gain velocity.
... Schwangerschaftswoche geboren werden, heute eine Überlebenschance von 50 %. 95 Die starke Unreife dieser besonders jungen Patienten hat eine höhere Rate an postnatalen Komplikationen als Konsequenz. 118 Dies wiederum trägt sowohl von Seiten der Eltern als auch aus medizinischer Sicht zu einem wachsenden Anspruch an eine optimale Versorgung dieser Patienten bei, um ihnen eine möglichst gute und normale Entwicklung zu ermöglichen. ...
Thesis
Wachstum von Frühgeborenen in Abhängigkeit von Variablen der enteralen und parenteralen Ernährung – Vergleich einer Kohorte des Jahrgangs 2002 mit dem Jahrgang 2013 Einleitung: Das Konzept der frühen und „aggressiven“ Ernährung von Frühgeborenen mit einem Geburtsgewicht unter 1500 g (VLBW), dass vor circa 15 Jahren von Thureen und Ziegler vorgestellt wurde, ist heutzutage medizinischer Standard. Ziel der Studie war es, etwaige Auswirkungen „aggressiver“ Ernährung auf die Entwicklung von Gewicht, Länge und Kopfumfang in einer Kohorte aller 2013 geborenen VLBW-Frühgeborenen festzustellen, verglichen mit einer Kohorte VLBW-Frühgeborener aus dem Jahrgang 2002, die nicht „aggressiv“ ernährt wurden. Methoden: Es wurde eine retrospektive Analyse von Patientendaten von der Geburt bis zum 50. Lebenstag durchgeführt. Erfasst wurden 1) anthropometrische Daten, entsprechend den Perzentilen nach Voigt (2006) und Umwandlung in z-Score-Differenzen und 2) detaillierte Ernährungsinformationen (Energie, parenterale vs. enterale Ernährung, Glucose, Protein, Fett und andere). Die statistische Auswertung erfolgte mit t-Test, Mann-Whitney-Test und Fisher´s exact Test. Das Signifikanzniveau wurde für p < 0,05 angenommen. Ergebnisse: 44 Frühgeborene des Jahrgangs 2013 und 42 Frühgeborene des Jahrgangs 2002 wurden eingeschlossen. Postmenstruelles Alter (Median 28 + 1/7 vs. 26 + 6/7), Geburtsgewicht und Kopfumfang waren 2013 signifikant größer als 2002. Dennoch unterschieden sich die z-Scores für das Geburtsgewicht, die Länge bei der Geburt und den Kopfumfang bei der Geburt nicht. Obwohl die Behandlungsdauer 2013 signifikant kürzer war (p = 0,002), war die Entwicklung des z-Scores für das Gewicht (p = 0,006) und die Länge (p = 0,001) signifikant besser als 2002. Dies traf nicht auf die Entwicklung des z-Scores für den Kopfumfang zu (p = 0,213). In einer multiplen linearen Regressionsanalyse mit zwei unterschiedlichen Modellen zeigten sich die Gesamtenergie, das Gesamtprotein, Gesamtfett und der SGA-Status als signifikant einflussnehmend für eine adäquate Gewichtszunahme zwischen Lebenstag 5 und Lebenstag 30. Schlussfolgerung: „Aggressive“ Ernährung hat möglicherweise einen differentiellen Effekt auf die anthropometrischen Maße, wobei dieser auf das Wachstum des Kopfumfangs bezogen geringer ist.
... Parenteral nutrition (PN) is commonly used as a critical life-saving nutritional supplement in the neonatal intensive care unit (NICU) until the immature neonatal gut can tolerate enteral nutrition [1]. Many NICU patients receiving PN have a diagnosis associated with intestinal failure [2], and are therefore unable to tolerate enteral nutrition [3]. ...
Article
Background: Intestinal Failure-Associated Liver Disease is characterized by cholestasis and hepatic dysfunction due to parenteral nutrition (PN) therapy. We described key features of cholestatic infants receiving PN to assess overall outcomes in this population at our institution. Methods: This is a retrospective single center study of 163 neonates grouped into cholestatic (n = 63) and non-cholestatic (n = 100) as defined by peak conjugated bilirubin of ≥2.0 mg/dL or < 0.8 mg/dL, respectively. Univariate and multiple regression models were used to study associations between variables and outcomes of interest. Results: Lower Apgar scores (4 ± 3 vs. 6 ± 3, p-value = <0.005 at 1 min; 6 ± 2 vs. 7 ± 2, p < 0.005 at 5 min) and lower birth weight (adj β [SE] = 0.62 [0.27], p-value = 0.024) were risk factors for developing cholestasis. Cholestatic infants were more likely to have had gastrointestinal surgery (31 [49%] vs. 15 [15%], p-value <0.005), received PN for a longer duration (40 ± 39 days vs. 11 ± 7 days, p-value <0.005), and started enteral feeds later in life (86 ± 23 days vs. 79 ± 20 days, p-value <0.005) when compared to non-cholestatic infants. Weight percentiles in cholestatic infants were lower both at hospital discharge (14 ± 19 vs. 24 ± 22, p-value <0.005) and at 6 months of age (24 ± 28 vs. 36 ± 31, p-value = 0.05). Conclusions: Cholestasis in the NICU is a multifactorial process, but it has a long lasting effect on prospective weight gain in infants who receive PN in the NICU. This finding highlights the importance of follow-up for adequate growth and the potential benefit from aggressive nutritional support.
... One of the most challenging issues in the management of preterm infants is providing standard nutritional support [1]. Early appropriate nutrition is vital not just for adequate postnatal growth but also for reduction of sepsis and possibly even retinopathy of prematurity [2][3][4]. ...
Article
Full-text available
Objective: To evaluate the effect of early total enteral feeding (ETEF) when compared with conventional enteral feeding (CEF) in stable very-low-birth-weight (VLBW; 1,000-1,499 g) infants on the postnatal age (in days) at attaining full enteral feeds. Methods: In this unblinded randomised controlled trial, 180 infants were allocated to an ETEF (n = 91) or a CEF group (n = 89). Feeds were initiated as total enteral feeds in the ETEF group and as minimal enteral nutrition (20 mL/kg) in the CEF group. The rest of the day's requirement in the CEF group was provided as parenteral fluids. The primary outcome was postnatal age at attaining full enteral feeds. The secondary outcomes included episodes of feed intolerance, incidence of sepsis and necrotising enterocolitis (NEC), and duration of hospital stay. Results: The baseline variables including birth weight and gestational age were similar in the two groups. The infants of the ETEF group attained full enteral feeds earlier than those of the CEF group (6.5 ± 1.5 vs. 10.1 ± 4.1 days postnatal age; mean difference -3.6 [-4.5 to -2.7]; p < 0.001). Total episodes of feed intolerance and clinical sepsis were fewer, with a shorter duration of hospital stay, in the ETEF group (15.5 vs. 19.6 days) (p = 0.01). The incidence of NEC was similar in the two groups. Conclusion: ETEF in stable VLBW infants results in earlier attainment of full feeds and decreases the duration of hospital stay without any increased risk of feed intolerance or NEC.
... Le graphique ci-dessous montre le changement de composition corporelle en fonction de l'âge. Figure 1 : Changement de la composition corporelle en fonction de l'âge (inspiré de (4) (8,9) . Un des facteurs de risque de développer une NEC, La composition moyenne en principaux nutriments est présentée dans le tableau ci-dessous. ...
Thesis
La grande variabilité des besoins nutritionnels de l'enfant peut demander la réalisation de mélanges de nutrition parentérale "à la carte". En analysant le processus de préparation de ces mélanges pédiatriques au CHU de Rouen, nous avons pu constater que deux points étaient à sécuriser. Le premier concerne l'analyse pharmaceutique. La mise en place d'un outil d'aide informatisé à l'analyse pharmaceutique a permis d'affiner l'analyse posologique et par conséquent de diminuer le nombre de dépassements des doses maximales recommandées et ainsi limiter les risques liés à un surdosage. Le second concerne le contrôle physico-chimique. Nous souhaitons mettre en place un contrôle en teneur de nos mélanges ternaires. Notre étude a montré que ces dosages étaient réalisables en routine par le laboratoire de biochimie. Pour le valider, il suffit d'adapter les marges d'acceptation en fonction des concentrations et de l'élément.
... Due to multiple factors, [10][11][12] it is not always possible to administer the nutrients orally or through enteral feedings, 13 and the only way to ensure that the newborn gets the necessary nutrients to sustain life is parenteral nutrition (PN). [14][15][16][17][18] To avoid any future consequences of malnutrition, it is recommended to start feedings or administering nutrients during the first 24-48 hours of life, seeking to maintain blood sugar levels in ideal ranges. 19,20 Therefore, periods of low nutrition intake and even fasting should be avoided because of their association with rapid nutrition deterioration. ...
Article
Full-text available
Parenteral support has increased the possibility of neonatal recovery. However, complications associated with its use have been documented. One commercial method developed to decrease the complications of this type of support is the ready‐to‐use parenteral nutrition (PN), a 3‐chamber bag that provides a complete nutrient mix. This systematic review seeks, through the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses methodology, to establish the benefits in newborns. Seven databases and gray literature were used. The search was limited to publications from 2007–2017 and to articles written in English, Spanish, and Portuguese. Articles that did not meet the inclusion criteria and studies with low quality evaluated with the Scottish Intercollegiate Guidelines Network guidelines, which were without information about the study or analytical methods, were excluded. A total of 24,193 articles were obtained, which were initially evaluated by title and abstract according to the inclusion criteria. A total of 24,167 articles were discarded, obtaining 27 eligible for follow‐up evaluation. After a detailed evaluation of the full text, 13 articles were selected. It was found that ready‐to‐use PN has the potential benefit to reduce the risks for infections, provide an adequate supply of nutrients, generate growth within the expected range, provide ease of use, decrease prescription errors, and potentially reduce costs. It is necessary to evaluate the short‐ and long‐term impact of its use.
... Most health care providers, guided by the American Academy of Pediatrics, strive to prescribe nutritional practices in the NICU to achieve growth comparable to intrauterine life (Hay, 2013;Kleinman, 2008;Puntis, 2006). Intrauterine growth is commonly used as the standard for extrauterine growth of preterm infants because a superior growth standard remains undefined (Fenton & Kim, 2013). ...
Article
Growth failure has not been consistently defined for preterm infants, which contributes to unclear clinical guidelines for optimal growth and development. Therefore, the purpose of this concept analysis was to identify all uses and attributes of the concept, present model and contrary cases, identify antecedents and consequences, define empirical referents, and provide an operational definition of growth failure among preterm infants in the NICU. © 2017 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses
... Despite following standard practices, the growth in preterm infants may not be optimal in most cases. Current nutritional strategies or practices being followed for intrauterine growth restriction (IUGR)/preterm infants are not able to prevent postnatal growth restriction (49). Extrauterine growth restriction (EUGR) is a serious issue in preterm LBW infants, with an incidence of about 28, 34, and 16% for weight, length, and head circumference, respectively (50). ...
Article
Full-text available
Preterm birth survivors are at a higher risk of growth and developmental disabilities compared to their term counterparts. Development of strategies to lower the complications of preterm birth forms the rising need of the hour. Appropriate nutrition is essential for the growth and development of preterm infants. Early administration of optimal nutrition to preterm birth survivors lowers the risk of adverse health outcomes and improves cognition in adulthood. A group of neonatologists, pediatricians, and nutrition experts convened to discuss and frame evidence-based recommendations for optimizing nutrition in preterm low birth weight (LBW) infants. The following were the primary recommendations of the panel: (1) enteral feeding is safe and may be preferred to parenteral nutrition due to the complications associated with the latter; however, parenteral nutrition may be a useful adjunct to enteral feeding in some critical cases; (2) early, fast, or continuous enteral feeding yields better outcomes compared to late, slow, or intermittent feeding, respectively; (3) routine use of nasogastric tubes is not advisable; (4) preterm infants can be fed while on ventilator or continuous positive airway pressure; (5) routine evaluation of gastric residuals and abdominal girth should be avoided; (6) expressed breast milk (EBM) is the first choice for feeding preterm infants due to its beneficial effects on cardiovascular, neurological, bone health, and growth outcomes; the second choice is donor pasteurized human milk; (7) EBM or donor milk may be fortified with human milk fortifiers, without increasing the osmolality of the milk, to meet the high protein requirements of preterm infants; (8) standard fortification is effective and safe but does not fulfill the high protein needs; (9) use of targeted and adjustable fortification, where possible, helps provide optimal nutrition; (10) optimizing weight gain in preterm infants prevents long-term cardiovascular complications; (11) checking for optimal weight and sucking/swallowing ability is essential prior to discharge of preterm infants; and (12) appropriate counseling and regular follow-up and monitoring after discharge will help achieve better long-term health outcomes. This consensus summary serves as a useful guide to clinicians in addressing the challenges and providing optimal nutrition to preterm LBW infants.
... T he goal for growth and nutrition for preterm infants is to achieve an extrauterine growth rate for anthropometric indices and body composition similar to those of a normal fetus of the same gestational age (1). Comparable with the rate of intrauterine growth, the expected growth velocity for premature infants is 15 g Á kg À1 Á day À1 (1,2). Inability to achieve this growth velocity increases the risk of infection and associated morbidity and mortality (3,4). ...
Article
The objectives of this study were to determine if implementation of standardized feeding guidelines in a neonatal intensive care unit had an effect on the administration of enteral nutrition, growth and bone and liver health. This was a retrospective chart review of infants ≤32 weeks gestation and ≤1500 grams at birth who either received enteral nutrition via traditional care (TC) or via standardized feeding guidelines (SFG). The outcomes of the study were to determine the day of life the first enteral feedings were started, the day of life full, fortified enteral feedings were established, the day of life the infant returned to birth weight, the change in weight Z-score from birth to day of life 30, and the presence of metabolic bone disease and cholestasis. There were 128 infants in the TC group and 125 infants in the SFG group. Based on cox regression, no significant differences were found between the two groups in the length of time to the first feed (p = 0.110; CI = 1.03-1.70) in the length to full, fortified enteral feedings (p = 0.334; CI = 0.87-1.44) in the length of time to return to birth weight (p = 0.545; CI = 0.77-1.28), incidence of metabolic bone disease (p = 0.990) or incidence of cholestasis (p = 0.926). This study provides preliminary evidence that SFG have an effect on enteral nutrition administration, growth and morbidity for preterm infants. Although the findings were not statistically significant they are clinically relevant.
... Breast milk is recommended as the primary source of nutrition and for promoting growth and development of preterm infants (O'connor et al. 2003;Puntis 2006). Breast milk shows immunological benefits and reduces the risks of developing diseases such as necrotizing enterocolitis or sepsis (Schanler et al. 1999). ...
Article
Commercially available milk analysers were originally developed for use in the dairy industry, but they are now used to analyse macronutrient content of breast milk in clinical studies and routine care of the premature or very low birthweight (VLBW) infants. Due to the different composition of cow and breast milk, these devices need to be validated against reference methods before they can be used in daily routine. However, current reference methods require a sample volume of 30-100 mL to analyse fat, protein and lactose. It is not feasible to obtain this volume of milk for research purposes, especially from VLBW infants as lactation may be delayed or impaired and the limited volume of breast milk must be provided to the infant. To support validation of milk analysers in both clinical and research settings, the aim of this study is to establish and validate micromethods for precise macronutrient analysis in small volume of breast milk and conduct a feasibility study of the micromethods as a post-validation. Methods include a modified Mojonnier ether extraction (fat), elemental analysis (protein) and ultra-performance liquid chromatography-tandem mass spectrometry (lactose). We were able to downsize volumes required for analysis of fat, protein and lactose to 1 mL, 260 μL and 100 μL; corresponding coefficients of variation are 1.7, 1.8 and 2.3%, respectively. The presented methods allow for reliable and precise analyses of macronutrients in ≤1.5 mL of breast milk and will be used to validate milk analysers.
... Although the EN has been described as the preferred NS practice to favor trophism and immunologic function and to avoid complications, 3,22,27,28 since the last decade the recommendation has been to start the NS with PN. 1,28 Most of the infants in our study received PN during the first two weeks of life; however, switching from PN to EN was done without MN, decreasing roughly the nutrient intake and resulting in less gain or even weight loss, as reported by Ehrenkranz. 5 McClure 9 reported that the weight gain was better with EN, with no differences between MN and PN in this respect. In this study, PN showed the best weight gain, followed by EN. ...
Article
Full-text available
To analyze the weight gain and to describe the metabolic complications in preterm newborns with nutritional support (NS) and to describe nutritional practices in the first month of hospitalization for 52 preterm newborns. Descriptive and prospective study of preterm infants (30-36 gestational weeks), with birth weight > 1 kg, hospital stay > 12 days, without respiratory support or complications, conducted at a public hospital in Leon, Guanajuato, Mexico from January to November 2006. Weight, serum glucose, insulin, cholesterol, triglycerides, gamma-glutamyltransferase, creatinine, urea nitrogen, type of NS (parenteral PN, enteral EN, mixed MN), energy content, and macronutrient intake were measured weekly. To obtain representative data, nutritional practices were not altered by the study protocol. One way ANOVA and Wilcoxon tests were used in data analyses. Overall, 52 newborns were included, averaging 33 gestational weeks and 1,590 g of weight. The NS was started by the fourth day on average. Parenteral nutrition was the most frequent NS during the first 2 weeks (75%). Energy and macronutrient supply was 50% less than the recommended. Weight gain ranged from -100 to 130 g/week. Parenteral nutrition showed better weekly weight gain, followed by EN. The metabolic complication rate per person-day was greater for MN (0.56), than for EN (0.16) or PN (0.09). Routine surveillance of weight and metabolic complications was deficient. Late onset of NS, insufficient energy supply, and deficient surveillance were obstacles to weight gain and to prevent the metabolic complications in these newborns.
... Nutritional support in the premature infants is of great importance since better survival rates can be achieved. The promotion of growth rates and nutrient accretion equivalent to those achieved during fetal development, the optimization of neurodevelopmental outcomes and the ensurance of long term health are important challenges for the abovementioned population [1]. These infants often cannot tolerate enteral feeding due to disease or immaturity of their intestinal tract and total parenteral nutrition (TPN) is the indicated nutritional support in order to decrease the risk of nutritional deficiencies and resultant complications [2]. ...
Article
Total parenteral nutrition is commonly used in neonates' intensive care units for nutritional support of preterm neonates. Adequacy and safety of parenteral nutrition support are amongst the major concerns of neonates' therapy. Parenteral nutrition prescription in Greek hospitals is not based on standardized protocols, thus resulting in wide diversity of formulations. In this study, the results of utilization of standardized computerized parenteral nutrition protocols and regimens for neonates are compared to the results of protocols and regimens prescribed by individual neonatologists on neonates' outcome (weight changes, adequacy of parenteral nutrition, days of hospitalization, clinical outcome). The study took place at "Mitera" Maternity Hospital of Greece. Two groups of 30 preterm infants (28-36 weeks) with respiratory failure were recruited for the study. They were admitted in a Greek maternity hospital and they all received total parenteral nutrition support in neonates' intensive care unit. Standardized, computer based protocols were applied for the prescription of parenteral nutrition formulations in the first group, while on the other, regimens prescribed by neonatologists were used. Macro- and micronutrients provided by the different total parenteral nutrition protocols were recorded. Body weight was measured, blood count and biochemical profile were performed at the beginning and at the end of parenteral nutrition support. The number of days of total parenteral nutrition support as well as the total number of days of hospitalization was recorded. Standardized protocols provided more energy (P-value: 0.05), protein (P-value: 0.023) and micronutrients than the non-standardised. Neonates that receive standardized total parenteral nutrition gained weight (+44 +/- 114 g) and had better blood count and biochemical values during total parenteral nutrition support compared to the other group, that lost weight during total parenteral nutrition support (-53 +/- 156 g). These differences were also statistically significant (P value < 0.05). Regarding the total days of hospitalization, no differences were found between the two groups. The use of standardized protocols in preterm neonates resulted in more adequate provision of nutrients, weight gain and better blood count profile compared with protocols prescribed by individual physicians.
... There is a long history of the safe operation of donor human milk banks internationally. Evidence is continuing to grow demonstrating the benefits of fortified human milk feeding of preterm infants, including the utilisation of pasteurised donor human milk [21]. Milk banks continue to attract criticism due to the variable nature of the macronutrient composition of the end product and concerns regarding the transmission of infectious agents through donor milk [8]. ...
Article
Full-text available
Until the establishment of the PREM Bank (Perron Rotary Express Milk Bank) donor human milk banking had not occurred in Australia for the past 20 years. In re-establishing donor human milk banking in Australia, the focus of the PREM Bank has been to develop a formal and consistent approach to safety and quality in processing during the operation of the human milk bank. There is currently no existing legislation in Australia that specifically regulates the operation of donor human milk banks. For this reason the PREM Bank has utilised existing and internationally recognised management practices for managing hazards during food production. These tools (specifically HACCP) have been used to guide the development of Standard Operating Procedures and Good Manufacturing Practice for the screening of donors and processing of donor human milk. Donor screening procedures are consistent with those recommended by other human milk banks operating internationally, and also consistent with the requirements for blood and tissue donation in Australia. Controlled documentation and record keep requirements have also been developed that allow complete traceability from individual donation to individual feed dispensed to recipient and maintain a record of all processing and storage conditions. These operational requirements have been developed to reduce any risk associated with feeding pasteurised donor human milk to hospitalised preterm or ill infants to acceptable levels.
... Also, the weight gain in our study far exceeded the weight gain of the babies reported by Khayata et al. (1987). The goal of postnatal feeding strategies is to reach the intrauterine growth rate of 10-15 g per kg per day (Puntis, 2006), which is not always possible to achieve in sick VLBW babies. ...
Article
Full-text available
In this retrospective study, we intended to test whether early enteral feeding (EEF) of very low birth weight (VLBW) preterm babies increases the risk of necrotizing enterocolitis (NEC) or not. Overall, 297 VLBW preterm babies admitted to the neonatal intensive care unit (NICU) between April 2003 and April 2006 were included. The study consisted of two periods: the first period was between April 2003 and October 2004, when babies were not fed enterally until they were extubated (167 preterm VLBWs). The second period was between November 2004 and April 2006, when babies were fed even when they were intubated, starting preferably on the first day of life (130 preterm VLBWs). Criteria for withholding enteral feeding in both periods were hypotension necessitating vasopressor agent use, abdominal distention, abdominal tenderness and suspected or proven NEC. Possible risk factors for NEC were also recorded. The overall incidence of NEC in VLBW preterm babies was 6.7% and did not differ between the two study periods: 7.2% in the late and 6.2% in the EEF regimens. On logistic regression analysis, the most important risk factors associated with NEC were sepsis (P<0.001) and blood culture positivity (P<0.001). The average daily weight gain was significantly higher in the early fed babies (P=0.011). The EEF of VLBW preterm babies does not increase the risk of NEC. Increased daily weight gain is an important reason to feed these babies earlier.
Article
Background Early nutritional challenges can lead to permanent metabolic changes, increasing risk of developing chronic diseases later in life. Total parenteral nutrition (TPN) is a life-saving nutrition regimen, used especially in intrauterine growth-restricted (IUGR) neonates. Early TPN feeding alters metabolism, but whether these alterations are permanent is unclear. Programmed metabolism is likely caused by epigenetic changes due to imbalances of methyl nutrients. Objectives We sought to determine whether feeding TPN in early life would increase risk of developing dyslipidemia in adulthood and whether supplementing the methyl nutrients betaine and creatine to TPN would prevent this development. We also sought to determine whether IUGR exacerbates the effects of neonatal TPN on lipid metabolism in adulthood. Methods Female piglets (n = 32; 7 d old) were used in 4 treatments: 24 normal-weight piglets were randomly assigned to sow-fed (SowFed), standard TPN (TPN-control), and TPN with betaine and creatine (TPN-B+C); 8 IUGR piglets were fed control TPN (TPN-IUGR) as a fourth group. After 2 wk of treatment, all pigs were then fed a standard solid diet. At 8 mo old, central venous catheters were implanted to conduct postprandial fat tolerance tests. Results Feeding TPN in the neonatal period led to dyslipidemia in adulthood, as indicated by higher postprandial triglyceride (TG) levels in TPN-control (P < 0.05), compared with SowFed. IUGR piglets were particularly sensitive to neonatal TPN feeding, as TPN-IUGR piglets developed obesity and dyslipidemia in adulthood, as indicated by greater backfat thickness (P < 0.05), higher liver TG (P < 0.05), slower postprandial TG clearance (P < 0.05), and elevated fasting plasma nonhigh-density lipoprotein-cholesterol (P < 0.01), and nonesterified fatty acids (P < 0.001), compared with TPN-control. Conclusions Feeding TPN in early life increases the risk of developing dyslipidemia in adulthood, especially in IUGR neonates; however, methyl nutrient supplementation to TPN did not prevent TPN-induced changes in lipid metabolism.
Article
Introduction: Providing adequate nutrition in the management of preterm infants has been challenging. The objective of this secondary analysis of data from the randomized trial comparing "less invasive surfactant therapy (LISA) with InSurE method of surfactant administration" is to demonstrate the feasibility of early total enteral feeding (ETEF) in hemodynamically stable preterm neonates on respiratory support and to examine the factors associated with failure of ETEF. Methods: Secondary analysis of a randomized controlled trial comparing "LISA versus InSurE among preterm infants between 26 and 34 weeks of gestation" enrolled 150 infants with 117 being hemodynamically stable. ETEF without any parenteral supplementation was started on day 1 of life using the mother's own milk (MoM) or donor human milk (<32 weeks of GA) and MoM or preterm formula (33-34 weeks of GA). The data were analyzed to assess the proportion of babies developing feed intolerance and/or necrotizing enterocolitis (NEC) and factors associated with failure of ETEF. All Infants were assessed for the day of attainment of full enteral feeding defined as receiving and tolerating 150 mL/kg of enteral feeds per day. Results: Out of these 117 babies, 102 tolerated ETEF, and 15 had one or more episodes of FI requiring total parenteral nutrition, but none developed NEC till discharge or death. On the assessment of possible factors associated with ETEF failure, there were no differences in baseline characteristics but statistically significantly increased incidence of culture-positive sepsis as well as the requirement of antibiotic therapy for possible sepsis (early as well as late-onset sepsis) in babies with failure of ETEF. The babies who tolerated ETEF achieved full enteral feeding (150 mL/kg/day) significantly earlier (5.48 ± 1.1 days) compared to those with ETEF failure (7 ± 3.4 days) (p 0.001). The time to regain birth weight was earlier in the ETEF group without significant differences in growth parameters. There was also a reduction in the duration of hospital stay in babies who tolerated ETEF, but both these results were not statistically significant. Conclusion: ETEF is feasible in preterm neonates with respiratory distress syndrome who are on respiratory support. It resulted in earlier attainment of full enteral feeds and decreased the incidence of sepsis with reduced antibiotic usage.
Article
Objective: To examine the change in breastfeeding behaviors over time, among low birth weight (LBW), very low birth weight (VLBW), and normal birth weight (NBW) infants using nationally representative US data. Study design: Univariate statistics and bivariate logistic models were examined using the Early Child Longitudinal Study-Birth Cohort (2001) and National Study of Children's Health (2007 and 2011/2012). Results: Breastfeeding behaviors improved for infants of all birth weights from 2007 to 2011/2012. In 2011/2012, a higher percentage of VLBW infants were ever breastfed compared with LBW and NBW infants. In 2011/2012, LBW infants had a 28% lower odds (95% CI, 0.57-0.92) of ever breastfeeding and a 52% lower odds (95% CI, 0.38-0.61) of breastfeeding for ≥6 months compared with NBW infants. Among black infants, a larger percentage of VLBW infants were breastfed for ≥6 months (26.2%) compared with LBW infants (14.9%). Conclusions: Breastfeeding rates for VLBW and NBW infants have improved over time. Both VLBW and NBW infants are close to meeting the Healthy People 2020 ever breastfeeding goal of 81.9%. LBW infants are farther from this goal than VLBW infants. The results suggest a need for policies that encourage breastfeeding specifically among LBW infants.
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Background: Feeding preterm infants in response to their hunger and satiation cues (responsive, cue-based, or infant-led feeding) rather than at scheduled intervals might enhance infants' and parents' experience and satisfaction, help in the establishment of independent oral feeding, increase nutrient intake and growth rates, and allow earlier hospital discharge. Objectives: To assess the effect of a policy of feeding preterm infants on a responsive basis versus feeding prescribed volumes at scheduled intervals on growth rates, levels of parent satisfaction, and time to hospital discharge. Search methods: We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 1), MEDLINE via PubMed (1966 to 17 February 2016), Embase (1980 to 17 February 2016), and CINAHL (1982 to 17 February 2016). We also searched clinical trials' databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. Selection criteria: Randomised controlled trials (RCTs) or quasi-RCTs that compared a policy of feeding preterm infants on a responsive basis versus feeding at scheduled intervals. Data collection and analysis: Two review authors assessed trial eligibility and risk of bias and undertook data extraction independently. We analysed the treatment effects in the individual trials and reported the risk ratio and risk difference for dichotomous data and mean difference (MD) for continuous data, with respective 95% confidence intervals (CIs). We used a fixed-effect model in meta-analyses and explored the potential causes of heterogeneity in sensitivity analyses. We assessed the quality of evidence at the outcome level using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results: We found nine eligible RCTs including 593 infants in total. These trials compared responsive with scheduled interval regimens in preterm infants in the transition phase from intragastric tube to oral feeding. The trials were generally small and contained various methodological weaknesses including lack of blinding and incomplete assessment of all randomised participants. Meta-analyses, although limited by data quality and availability, suggest that responsive feeding results in slightly slower rates of weight gain (MD -1.36, 95% CI -2.44 to -0.29 g/kg/day), and provide some evidence that responsive feeding reduces the time taken for infants to transition from enteral tube to oral feeding (MD -5.53, 95% CI -6.80 to -4.25 days). GRADE assessments indicated low quality of evidence. The importance of this finding is uncertain as the trials did not find a strong or consistent effect on the duration of hospitalisation. None of the included trials reported any parent, caregiver, or staff views. Authors' conclusions: Overall, the data do not provide strong or consistent evidence that responsive feeding affects important outcomes for preterm infants or their families. Some (low quality) evidence exists that preterm infants fed in response to feeding and satiation cues achieve full oral feeding earlier than infants fed prescribed volumes at scheduled intervals. This finding should be interpreted cautiously because of methodological weaknesses in the included trials. A large RCT would be needed to confirm this finding and to determine if responsive feeding of preterm infants affects other important outcomes.
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Especialidades médicas relacionadas, producción bibliográfica y referencias profesionales de la autora. Ganancia de peso e impacto metabólico como resultados de la terapia nutricional en neonatos prematuros hospitalizados Nutritional therapy in hospitalized preterm neonates: weight gain and metabolic impact Estadísticas De acuerdo con la Organización Mundial de la Salud (OMS), el nacimiento prematuro se considera como el na-cimiento que se da antes de completarse la semana 37 de gestación, independientemente del peso al nacer. 1-3 El nacimiento prematuro es la principal causa de mortalidad entre recién nacidos, sobre todo dentro de las cuatro se-manas de vida; pero también es considerada la segunda causa de muerte después de la neumonía en niños me-nores de 5 años. 1 A nivel mundial, las estadísticas de nacimiento prema-turo son de 15 millones al año y en los países en desar-rollo la prevalencia es del 5% al 18%, donde un 20% de ellos presenta algún tipo de desnutrición; mientras que la incidencia de nacimiento prematuro es del 11% en Amé-rica del Norte, 5.6% en Oceanía y 5.8% en Europa. 1-2 En los Estados Unidos, las estadísticas siguen en aumento, de un 9.5% de nacimientos prematuros en 1981 se pasó a 12.7% para 2005. 1-2 Por su parte, México presenta una prevalencia de prematuridad del 7.3% con 135 820 nacimientos prematuros entre las 32 y las 37 semanas de gestación durante 2011. 5-7 En Guanajuato, en la última década, la Secretaría de Salud informó un incremento del índice de nacimientos prematuros del 6% al 10%, con 1783 nacimientos prematuros, con un promedio de 17 nacimientos a la semana. 7 A pesar de todos los esfuerzos realizados desde los ám-bitos clínico y de investigación, la frecuencia de prematu-ridad sigue en aumento. 1 La prematuridad y el bajo peso al nacer se asocian en un 30%, lo cual condiciona una mayor morbilidad y mortalidad neonatal. Terapia nutricional Los niños prematuros no siguen el patrón de crecimien-to fetal ni el patrón de crecimiento de los recién nacidos a término. El desarrollo de estos neonatos tiene lugar en el siguiente orden: primero, un retraso de crecimiento pos-natal; luego, un período de transición, y finalmente, un período de recuperación del crecimiento. Los neonatos prematuros presentan con frecuencia problemas de alimentación a causa del desarrollo insufi-ciente de sus reflejos de succión y deglución, inmadurez Abstract Preterm birth, according to the World Health Organization, is defined as childbirth occurring before 37 weeks of gestation. Due to an immaturity of various organs and systems, coupled with greater energy requirements, these newborns are at a greater risk of metabolic and infectious complications. Because of this, the majority of preterm infants require hospitalization and feeding by routes other than orally, such as nutritional support or nutritional therapy (NT). NT is a procedure that allows energy and nutritional requirements to be covered by different routes: enteral, parenteral or mixed. However, this procedure , like any other, has risks and benefits, so there are guidelines for its prescription and consequent surveillance. A study by the author in hospitalized preterm infants receiving NT found higher metabolic risks and poor weight gain; some of the causes were null surveillance and monitoring of NT. The results and evidence gathered by the author led to a search for better management practices. This generated a standardized management protocol for NT. Adequate feeding practices and nutritional care during hospitalization for preterm infants are key to improving survival, adequate weight gain and development, resulting in lower metabolic risks and complications. Resumen El nacimiento pretérmino, de acuerdo con la Organización Mundial de la Salud, es el producto que nace antes de la semana 37 de gestación y, debido a la madurez de varios órganos y sistemas, aunado a un mayor requerimiento energético, incrementa el riesgo de presentar mayores riesgos metabólicos e infecciosos. Así, la mayoría de los neonatos requerirán ser hospitalizados y alimentados por otra vía diferente a la oral, como la terapia nutricional o soporte nutricio (TN). La TN es un procedimiento que permite cubrir los requerimientos energéticos y de nutrimentos por diferentes vías: enteral, parenteral o mixta. Pero este procedimiento, como cualquier otro, presenta riesgos y beneficios, por lo que se cuenta con guías y lineamientos para su prescripción adecuada y, por ende, su vigilancia. Un estudio de la autora, en prematuros hospitalizados y alimentados con TN, encontró mayores riesgos metabólicos y una deficiente ganancia de peso; algunas de las causas fue la nula vigilancia y supervisión de la TN. Los resultados permitieron buscar estrategias de mejores prácticas, que llevó a generar un protocolo estandarizado de manejo de la TN. Las buenas prácticas de alimentación y la vigilancia nutricia durante la hospitalización de los neonatos prematuros son clave para mejorar la supervivencia, la ganancia de peso y el adecuado desarrollo fetal, traducido en menores riesgos y complicaciones metabólicas. Palabras clave: neonato prematuro, ganancia de peso, hiperglucemia, nutrición parenteral
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El paciente grave se caracteriza por presentar alteraciones en el balance metabólico nutricional, debido a una compleja desregulación de diferentes vías de señalización, lo que en buena parte es condicionado por una intensa respuesta inmunoinflamatoria que se incrementa por la activación de la inmunidad innata y la disfunción de sus mecanismos contrarreguladores. Como resultado de esto se presenta un estado hipercatabólico que trae consigo una depleción de los diferentes compartimentos corporales, en especial la masa muscular y la reserva proteica.Este mecanismo favorece un estado de mayor disfunción inmunorreguladora que amplifica el estado catabólico y la depleción progresiva de la reserva energética y funcional de los diferentes órganos.Si lo anterior no se modifica de alguna manera, se favorecen y perpetúan la inmunoparálisis, las disfunciones orgánicas y la dependencia del paciente de diferentes terapias de soporte, lo que favorece un círculo vicioso que puede ocasionarle la muerte.Pocas maniobras terapéuticas han logrado modificar este complejo comportamiento fisiopatológico y mejorar la sobrevida de los enfermos; una de ellas es la terapia nutricional.La terapia nutricional en el paciente grave, junto con las novedosas técnicas de reanimación, los antibióticos y la ventilación mecánica, son los pilares del abordaje terapéutico en los pacientes internados en la unidad de terapia intensiva. A partir de las aportaciones del Dr. Stanley Dudrick quedó claro y bien fundamentado el hecho de que la terapia nutricional es parte del manejo temprano de los pacientes que cursan con un padecimiento grave. Esto se ha corroborado al paso de los años; en la actualidad es contundente la evidencia científica que demuestra que la evaluación y una adecuada terapia nutricional disminuyen las complicaciones, la estancia hospitalaria, los días de ventilación mecánica y la mortalidad.Por lo que creímos conveniente desarrollar un texto en el que se analicen tópicos actuales de la terapia nutricional en el paciente grave con el objetivo de crear conciencia en todos los profesionales de la salud involucrados en el manejo de ellos, poniendo a su alcance los conceptos más actuales relacionados con la evaluación nutricional, el cálculo energético y la terapia nutricional en diferentes escenarios tanto en el paciente adulto como en el paciente pediátrico en estado crítico.En este libro se conjuntan los esfuerzos de un gran número de expertos en cada uno de los temas tratados; sin embargo, hay que resaltar el trabajo de la distinguida Dra. Martha Patricia Márquez y su grupo del Instituto Nacional de Pediatría, ya que con su apoyo fue posible contar con los capítulos de abordaje y terapia nutricional en el niño grave. Por último, es prioritario enfatizar que la terapia nutricional en el paciente grave, como se practica en la actualidad, se debe a la contribución y el esfuerzo de distinguidos académicos.
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Background: Feeding preterm infants in response to their hunger and satiation cues (responsive, cue-based, or infant-led feeding) rather than at scheduled intervals might enhance infants' and parents' experience and satisfaction, help in the establishment of independent oral feeding, increase nutrient intake and growth rates, and allow earlier hospital discharge. Objectives: To assess the effect of feeding preterm infants on a responsive basis versus feeding prescribed volumes at scheduled intervals on growth, duration of hospital stay, and parental satisfaction. Search methods: We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 9, 2015), MEDLINE (1966 to September 2015), EMBASE (1980 to September 2015), and CINAHL (1982 to September 2015), conference proceedings, previous reviews, and trial registries. Selection criteria: Randomised controlled trials (RCTs) or quasi-RCTs that compared a policy of feeding preterm infants on a responsive basis versus feeding at scheduled intervals. Data collection and analysis: Two review authors assessed trial eligibility and risk of bias and undertook data extraction independently. We analysed the treatment effects in the individual trials and reported the risk ratio and risk difference for dichotomous data and mean difference (MD) for continuous data, with respective 95% confidence intervals (CIs). We used a fixed-effect model in meta-analyses and explored the potential causes of heterogeneity in sensitivity analyses. Main results: We found nine eligible RCTs including 593 infants in total. These trials compared responsive with scheduled interval regimens in preterm infants in the transition phase from intragastric tube to oral feeding. The trials were generally small and contained various methodological weaknesses including lack of blinding and incomplete assessment of all randomised participants. Meta-analyses, although limited by data quality and availability, suggest that responsive feeding results in slightly slower rates of weight gain (MD -1.4, 95% CI -2.4 to -0.3 g/kg/day), and provide some evidence that responsive feeding reduces the time taken for infants to transition from enteral tube to oral feeding (MD -5.5, 95% CI -6.8 to -4.2 days). The importance of this finding is uncertain as the trials did not find a strong or consistent effect on the duration of hospitalisation. None of the included trials reported any parent, caregiver, or staff views. Authors' conclusions: Overall, the data do not provide strong or consistent evidence that responsive feeding affects important outcomes for preterm infants or their families. Some evidence exists that preterm infants fed in response to feeding and satiation cues achieve full oral feeding earlier than infants fed prescribed volumes at scheduled intervals. However, this finding should be interpreted cautiously because of methodological weaknesses in the included trials. A large RCT would be needed to confirm this finding and to determine if responsive feeding of preterm infants affects other important outcomes.
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Parenteral nutrition (PN) improves the growth and outcome of very low birth weight (VLBW) infants. Optimal PN composition, standard (STD-PN) or individualized (IND-PN), is still controversial. To compare IND-PN and STD-PN as to nutritional and growth parameters, complications and cost. 140 VLBW infants were studied. Each of the 70 neonates from the IND-PN group was matched with a neonate of similar gestational age (GA; +/-4 days) on STD-PN. Data collection included demographic, maternal, intrapartum, neonatal, interventional, growth and nutritional data. Compared to STD-PN infants, IND-PN infants had a significantly lower mean birth weight, greater need for resuscitation at birth and interventions thereafter. Nevertheless, IND-PN infants showed significantly greater weight gain SDS during the 1st week (p = 0.036) and the 1st month of life (p = 0.0004), and higher discharge weight SDS (p = 0.012) and head circumference SDS (p = 0.006). IND-PN infants received higher mean daily caloric intakes. They also had significantly shorter durations of exclusive PN and needed less electrolyte corrections. Compared to STD-PN infants, IND-PN infants achieved significantly better growth without added clinical or laboratory complications, had a shorter period of exclusive PN and less electrolyte corrections. IND-PN, in accordance with the current more aggressive nutritional approach, appears optimal for PN of VLBW infants. Yet, STD-PN with adequate composition is an appropriate alternative.
Article
The requirements of growth and organ development create a challenge in nutritional management of newborn infants, especially premature newborn and intestinal-failure infants. Since their feeding may increase the risk of necrotizing enterocolitis, some high-risk infants receive a small volume of feeding or parenteral nutrition (PN) without enteral feeding. This review summarizes the current research progress in the nutritional management of newborn infants. Searches of MEDLINE (1998-2007), Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2007), abstracts and conference proceedings, references from relevant publications in the English language were performed, showing that breast milk is the preferred source of nutrients for enteral feeding of newborn infants. The number of nutrients found in human milk was recommended as a guideline in establishing the minimum and maximum levels in infant formulas. The fear of necrotizing enterocolitis and feeding intolerance are the major factors limiting the use of the enteral route as the primary means of nourishing premature infants. PN may help to meet many of the nutritional needs of these infants, but has significant detrimental side effects. Trophic feedings (small volume of feeding given at the same rate for at least 5 d) during PN are a strategy to enhance the feeding tolerance and decrease the side effects of PN and the time to achieve full feeding. Human milk is a key component of any strategy for enteral nutrition of all infants. However, the amounts of calcium, phosphorus, zinc and other nutrients are inadequate to meet the needs of the very low birth weight (VLBW) infants during growth. Therefore, safe and effective means to fortify human milk are essential to the care of VLBW infants.
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A nitrogen source based on egg protein (Vamin 9 glucose) and an alternative with an amino acid profile more similar to breast milk (Vaminolact), were compared in 14 parenterally fed infants. Subjects were randomly allocated to receive one or other amino acid solution, but were otherwise given identical diets. At the start of the study the two groups did not differ significantly in postconceptual age, postnatal age, or weight. Over a six day study period on a stable intake of intravenous nutrients there was no significant difference in growth or nitrogen retention between the two groups. Plasma amino acid profiles in those receiving Vamin 9 glucose, however, were frequently abnormal. Notably, mean concentrations of potentially neurotoxic phenylalanine and tyrosine were significantly higher (140% and 420%, respectively) in patients fed Vamin 9 compared with those given Vaminolact. An amino acid solution based on the composition of breast milk protein therefore brings plasma amino acid profiles during parenteral nutrition closer to those found in breast fed infants, and reduces in particular, the risks of hyperphenylalaninaemia and hypertyrosinaemia.
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A large multicentre study on the short and long term clinical and developmental outcome of infants randomised to different diets is being undertaken. This report represents an interim analysis of the early postnatal growth performance of an unselected population of 194 preterm infants (gestation, mean (SD) 31 . 0 (2 . 9) weeks; birthweight, mean (SD) 1364 (294) g), both ill and well, examined in two (of four) parallel trials. One trial compared banked breast milk with a new preterm formula (primary trial); the other compared these diets as supplements to maternal milk (supplement trial). A major dietary effect on the number of days taken to regain birthweight and subsequent gains in weight, length, and head circumference was observed in the primary trial. Infants fed banked breast milk and weighing less than 1200 g at birth took a calculated additional three weeks to reach 2000 g compared with those fed on the preterm formula. A significant influence of diet on body proportions was seen in the relation between body weight, head circumference, and length. Similar though smaller differences in growth patterns were seen in the supplement trial. By the time they reach 2000 g, infants of birthweights 1200 to 1849 g fed on banked breast milk and infants below 1200 g fed on either banked breast milk or maternal milk supplemented (as necessary) with banked breast milk, fulfilled stringent criteria for failure to thrive (weight less than 2 SD below the mean for age). Only infants fed the preterm formula as their sole diet had maintained their birth centile by discharge from hospital. The misleading nature of comparisons between extrauterine and intrauterine steady state weight gains is emphasised.
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Despite potential benefits, human milk may fail to meet preterm infants' nutrient requirements. We tested the hypothesis that fortified breast milk, fed alone or with preterm formula, would improve neurodevelopment and growth at 18-mo follow-up without adverse short-term clinical or biochemical consequences. Two hundred seventy-five preterm infants from two medical centers (birth weight < 1850 g; mean gestation 29.8 +/- 2.7 wk) whose mothers chose to provide breast milk were randomly assigned to receive for a mean of 39 d a multinutrient fortifier or control supplement containing phosphate and vitamins. Breast milk comprised 47.6% and 46.4% of enteral intake in fortified and control groups, respectively; preterm formula supplements were used when insufficient breast milk was available. Overall, there were no significant growth advantages with fortification; although, when breast milk exceeded 50% of intake, fortification promoted faster weight gain (an advantage of 1.6 g.kg-1.d-1; 95% CI: 0.1, 3.1; P < 0.05). Compared with control infants, the fortified group showed 1) higher plasma urea from week 2 (P = 0.04), 2) higher plasma calcium (mean 2.34 +/- 0.01 compared with 2.27 +/- 0.02 mmol/L; P = 0.003), 3) a greater rise in alkaline phosphatase by week 6 (P = 0.04), 4) more clinical infections (suspected plus proven; 43% compared with 31%, P = 0.04), 5) a nonsignificantly increased incidence of necrotizing enterocolitis (5.8% compared with 2.2%, P = 0.12), and 6) higher white cell and platelet counts. Developmental scores at 18 mo were slightly but not significantly higher in the fortified group. This study confirmed that breast milk fortifiers can improve short-term growth (when breast milk intakes are high); but beneficial effects on long-term development remained unproven. Future research is required to evaluate potential adverse consequences and explore more optimal fortification strategies.
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In a large-scale study of feeding strategies in premature infants (early vs later initiation of enteral feeding, continuous vs bolus tube-feeding, and human milk vs formula), the feeding of human milk had more effect on the outcomes measured than any other strategy studied. Therefore, this report describes the growth, nutritional status, feeding tolerance, and health of participating premature infants who were fed fortified human milk (FHM) in comparison with those who were fed exclusively preterm formula (PF). Premature infants were assigned randomly in a balanced two-way design to early (gastrointestinal priming for 10 days) versus late initiation of feeding (total parenteral nutrition only) and continuous infusion versus intermittent bolus tube-feeding groups. The type of milk was determined by parental choice and infants to receive their mother's milk were randomized separately from those to receive formula. The duration of the study spanned the entire hospitalization of the infant. To evaluate human milk versus formula feeding, we compared outcomes of infants fed >50 mL. kg-1. day-1 of any human milk (averaged throughout the hospitalization) with those of infants fed exclusively PF. Growth, feeding tolerance, and health status were measured daily. Serum indices of nutritional status were measured serially, and 72-hour nutrient balance studies were conducted at 6 and 9 weeks postnatally. A total of 108 infants were fed either >50 mL. kg-1. day-1 human milk (FHM, n = 62) or exclusively PF (n = 46). Gestational age (28 +/- 1 weeks each), birth weight (1.07 +/- 0.17 vs 1.04 +/- 0.19 kg), birth length and head circumference, and distribution among feeding strategies were similar between groups. Infants fed FHM were discharged earlier (73 +/- 19 vs 88 +/- 47 days) despite significantly slower rates of weight gain (22 +/- 7 vs 26 +/- 6 g. kg-1. day-1), length increment (0.8 +/- 0.3 vs 1.0 +/- 0.3 cm. week-1), and increment in the sum of five skinfold measurements (0.86 +/- 0.40 vs 1.23 +/- 0.42 mm. week-1) than infants fed PF. The incidence of necrotizing enterocolitis and late-onset sepsis was less in the FHM group. Overall, there were no differences in any measure of feeding tolerance between groups. Milk intakes of infants fed FHM were significantly greater than those fed PF (180 +/- 13 vs 157 +/- 10 mL. kg-1. day-1). The intakes of nitrogen and copper were higher and magnesium and zinc were lower in group FHM versus PF. Fat and energy absorption were lower and phosphorus, zinc, and copper absorption were higher in group FHM versus PF. The postnatal retention (balance) surpassed the intrauterine accretion rate of nitrogen, phosphorus, magnesium, zinc, and copper in the FHM group, and of nitrogen, magnesium, and copper in the PF group. Although the study does not allow a comparison of FHM with unfortified human milk, the data suggest that the unique properties of human milk promote an improved host defense and gastrointestinal function compared with the feeding of formula. The benefits of improved health (less sepsis and necrotizing enterocolitis) associated with the feeding of FHM outweighed the slower rate of growth observed, suggesting that the feeding of FHM should be promoted actively in premature infants.
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Our purpose in this study was to examine whole body composition, using dual energy x-ray absorptiometry (DEXA) during dietary intervention in preterm infants (< or = 1750 g birthweight, < or = 34 wk gestation). At discharge, infants were randomized to be fed either a preterm infant formula (discharge-6 mo; group A) or a term formula (discharge-6 mo; group B), or the preterm formula (discharge-term) and the term formula (term-6 mo; group C). Nutrient intake was measured between each clinic visit. To measure body composition, DEXA was used at discharge, term, 12 wk, 6 mo, and 12 mo corrected age. The data were analyzed by ANOVA. At discharge, no differences were noted in patient characteristics between groups A, B, and C. Although energy intakes were similar, protein and mineral intakes differed between groups (A > C > B; p < 0.0001). During the study, weight gain and LM gain were greater in group A than B. At 12 mo, weight, LM, FM, and BMM but not % FM or BMD were greater in group A than B. However, the effects of diet were confined to boys, with no lasting effects seen in girls. In summary, therefore, DEXA was precise enough to detect differences in whole body composition during dietary intervention. Increased weight gain primarily reflected an increase in LM and is consistent with the idea that the preterm formula more closely met protein and/or protein-energy needs in rapidly growing preterm male infants.
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To explain differences in weight growth velocity of extremely premature infants among 6 level III neonatal intensive care units (NICUs). In 6 NICUs, we studied 564 infants, stratified by gestational age (GA), who were first admissions, survivors, <30 weeks' GA at birth, and in the NICU at least 16 days. Case mix (eg, birth weight, GA, race, illness severity, prenatal steroids), exposure to medical practices/complications (eg, respiratory support, postnatal steroids, necrotizing enterocolitis, infection), and nutritional intake (kcal/kg/d and protein in g/kg/d) were collected and used to predict weight growth velocity between day 3 and day 28 (or discharge, if transferred early) in multiple linear regression models. Weight growth velocities varied significantly among the 6 NICUs. Adjustment for case mix and medical factors explained little of this variability, but additional control for calorie and especially protein intake accounted for much of the intersite variability. For the average infant, adjusted growth velocity ranged from 10.4 to 14.3 g/kg/d among the sites studied. The final predictive model, including case mix and medical and nutritional factors, explained 53% of the overall variance in growth velocity. Prolonged (> or =15 days) exposure to postnatal steroids and greater severity of illness both decreased growth velocity. The model predicted that adding 1 g/kg/d protein to the mean intake for our sample would increase growth by 4.1 g/kg/d. Variation in nutrition explained much of the difference in growth among the NICUs studied. Mean intake of calories and protein failed to meet recommended levels, and the average growth in only 1 NICU approximated intrauterine growth standards. Increasing nutritional intake into the recommended ranges, in particular of protein, may increase growth of extremely premature infants up to or above intrauterine rates.
Article
Lipid emulsions are essential components of parenteral nutrition of infants and small children to meet their high energy requirements and to provide essential polyunsaturated fatty acids (PUFA). In neonates and low birthweight infants, the amount and the quality of the nutritional lipids is of particular functional importance because of the rapid growth and the very limited endogenous lipid stores. The availability and the metabolism of membrane components such as long-chain polyunsaturated fatty acids (LC-PUFA), phospholipids and cholesterol have direct effects on the functions of cell membranes. Several studies show that the early supply of docosahexaenoic acid influences visual and cognitive functions at later ages. LC-PUFA also regulate gene expression and serve as substrates for the formation of the bioactive eicosanoids prostaglandins, thromboxanes and leukotrienes, which modulate thrombocyte aggregation, inflammatory reactions, postnatal closure of the ductus arteriosus and development of immune phenotypes. Most infants >28 gestational weeks clear 2 g intavenous lipids per kg bodyweight daily, and infants >32 weeks up to 3 g/kg. About 30% of infants between the 27th and 32nd gestational week develop lipid concentrations in the serum >100 mg/dl with lipid infusions dosed at 2 to 3 g/kg, which, however, are also regularly observed in enterally fed infants. An increased risk for hypertriglyceridemia exists in very immature infants <28 gestational weeks and in severe infections or distress, where serum triglyceride concentrations should be measured. It appears reasonable to adjust the lipid dose to avoid serum triglycericles >200 mg/dl. Retrospective studies had raised concerns on potential adverse effects of an early lipid supply in preterm infants on later rates of chronic lung disease and mortality, but a meta-analysis of five prospective controlled studies showed no adverse effects of intravenous lipids within the first 5 days of life. Lipid emulsions based on soy bean oil have been traditionally used in paediatric patients but the adequacy of this practice has been challenged, primarily because of the high PUFA content and low vitamin E content. More recently, alternative lipid emulsions have been made available for paediatric clinical practice. These emulsions contain physical admixtures of medium-chain triglycerides (MCT) and soy bean oil thereby reducing the amount of PUFA. A lipid emulsion on the basis of olive oil and soy bean oil provides a reduced content of PUFA and larger proportions of oleic acid. New products with preformed long-chain n-3 fatty acids derived from marine fish oil have become available and may improve the n-3 fatty acid status in infancy.
Article
• To test the hypothesis that delayed oral feedings would lower the incidence of necrotizing enterocolitis (NEC) in neonates weighing less than 1,500 g at birth, we compared the incidence of NEC in two matched groups of newborns. High-risk neonates were selected from 160 consecutive admissions, based on a cumulative risk scoring of their illness during the first three days of life. One group (N = 20) was given no oral feedings for two weeks, receiving nutrition parenterally, while the other (N = 18) was given incremental enteric feedings of dilute infant formula or breast milk during the first two weeks of life. The overall incidence of NEC in the parenterally fed group was 60% (12/20) compared with 22% (4/18) in the early-oral-feeding group. These data show that withholding oral feedings for two weeks postnatally does not lower the incidence of NEC and in fact may promote its occurrence. (AJDC 1985;139:385-389)
Article
Fifty-two consecutlve infants admitted to a regional neonatal unit and requiring parenteral nutrition were randomly allocated to receive feeds based on either a ‘standard bag’ regimen in which the volume of amino acid and dextrose solutions were given in a fixed ratio of 1:3, but with flexible electrolyte addition, or a computer-assisted regimen, taking into account fluid and nutrient composition of partial enteral feeds, additional intravenous fluids and arterial flushes. The aim of the study was to assess whether the computer-generated prescription would reduce parenteral nutrition solution waste, improve electrolyte balance and promote growth when compared with the less flexible ‘standard bag’ approach. There was no difference in wastage of parenteral nutrition solution, biochemical stability (as indicated by plasma sodium or phosphate), or weight gain between the two groups. We conclude that the considerable flexibility afforded by computer-assisted prescribing may be of little benefit to most patients.
Article
We studied the occurrence of necrotizing enterocolitis in 2681 very low birth weight infants during an 18-month period to characterize the biodemographic and clinical correlates. Proven necrotizing enterocolitis (Bell stage II and beyond) occurred in 10.1% of study infants; necrotizing enterocolitis was suspected in 17.2% of study infants. Positivity of blood cultures was related to necrotizing enterocolitis staging. The mortality rate increased only for stage III necrotizing enterocolitis (54% died). Logistic regression identified medical center of birth, race, gender, birth weight, maternal hemorrhage, duration of ruptured membranes, and cesarean section as significant risk factors. For one center the odds ratio was 3.7, whereas for another center it was only 0.3. For black boys, the odds ratio was 2.3 relative to nonblack boys; for girls, race did not affect prevalence of necrotizing enterocolitis. Age at onset was related to birth weight and gestational age. Intercenter differences in necrotizing enterocolitis prevalence were related to time required to regain birth weight and other indicators of fluid management. Gram-positive organisms predominated in positive blood cultures for stage I and II necrotizing enterocolitis; enteric bacteria were isolated more frequently in infants with stage III disease. We conclude that necrotizing enterocolitis prevalence varies greatly among centers; this may be related to early clinical practices of neonatal care.
Article
That early nutrition and growth could affect cardiovascular disease (CVD) later in life has intrigued the public and scientific community. However, most published data are observational and retrospective, making interpretation difficult and providing an insecure basis for practice. Prompted by animal studies on long-term effects of early nutrition, we initiated intervention studies with strict experimental design to test the importance of early nutrition in humans. Long-term findings are now emerging. We showed that early postnatal nutrition permanently affects the major components of the metabolic syndrome—hypertension, dyslipidaemia, obesity, and insulin resistance—that affect propensity to CVD. Here we discuss our new findings together with existing studies in man and animals, and propose a synthesis with major implications for public-health practice and future research.
Article
The incidence of necrotizing enterocolitis in the newborn infant has increased within the same time period that increasing emphasis has been placed on oral alimentation of very small infants. A prospective investigation was conducted to determine the nutritional efficacy as well as the incidence of necrotizing enterocolitis of a standard cow milk formula compared with an elemental formula. Sixteen infants who weighed less than 1,200 gm were randomized and fed one of the two formulas. The clinical status of the two groups was similar. Seven of eight (87.5%) infants fed the elemental formula and two of eitht (25%) fed the standard cow milk formula developed necrotizing enterocolitis (p less than 0.02). The hypertonicity of the elemental diet may have contributed to the increased incidence of necrotizing enterocolitis in infants fed this formula.
Article
There is considerable controversy over whether nutrition in early life has a long-term influence on neurodevelopment. We have shown previously that, in preterm infants, mother's choice to provide breast milk was associated with higher developmental scores at 18 months. We now report data on intelligence quotient (IQ) in the same children seen at 7 1/2-8 years. IQ was assessed in 300 children with an abbreviated version of the Weschler Intelligence Scale for Children (revised Anglicised). Children who had consumed mother's milk in the early weeks of life had a significantly higher IQ at 7 1/2-8 years than did those who received no maternal milk. An 8.3 point advantage (over half a standard deviation) in IQ remained even after adjustment for differences between groups in mother's education and social class (p less than 0.0001). This advantage was associated with being fed mother's milk by tube rather than with the process of breastfeeding. There was a dose-response relation between the proportion of mother's milk in the diet and subsequent IQ. Children whose mothers chose to provide milk but failed to do so had the same IQ as those whose mothers elected not to provide breast milk. Although these results could be explained by differences between groups in parenting skills or genetic potential (even after adjustment for social and educational factors), our data point to a beneficial effect of human milk on neurodevelopment.
Article
In spite of a number of studies on necrotizing enterocolitis, there remains controversy concerning prevention regimens, especially with regard to enteral alimentation. This report is of a matched case-control study of the relationship of necrotizing enterocolitis to timing of first feeding, size of feeding volumes and increments, and a risk factor index in 59 case patients with necrotizing enterocolitis and 59 matched control patients. Comparison with control patients showed that case patients were fed earlier, received full-strength formula sooner, and received larger feeding volumes and increments. More highly stressed infants, as measured by the risk index, were more vulnerable to larger feeding increments. Among case patients there was significant correlation of age at first feeding and age at diagnosis (p < 0.0001) even after control for birth weight and risk index score, indicating that delayed feeding was related to delayed onset of disease. These analyses support the theory that earlier, more rapid feeding places stressed infants at greater risk for the development of necrotizing enterocolitis, and that infants with more severe respiratory problems are more vulnerable to such feeding practices.
Article
A comparative study of bowel colonisation and incidence of necrotising enterocolitis in neonates admitted to an intensive care unit is reported. Neonates of less than 33 weeks gestational age requiring mechanical ventilation for respiratory distress syndrome were randomised during the first week of life to receive either vancomycin and aztreonam or vancomycin and gentamicin for episodes of suspected sepsis after the first week of life. A higher proportion of neonates who received vancomycin and gentamicin had faecal colonisation with enterobacteriaceae at the end of the second, third, and fourth weeks of life. Treatment with vancomycin and aztreonam was associated with a rapid quantitative reduction in faecal colonisation with enterobacteriaceae, whereas there was no quantitative reduction in colonisation with enterobacteriaceae associated with treatment with vancomycin and gentamicin. There were no differences between the two groups in faecal colonisation with anaerobes, Enterococcus sp, Staphylococcus sp, or yeasts. Six (14.6%) of 41 who received vancomycin and gentamicin compared with 0 of 40 who received vancomycin and aztreonam subsequently developed necrotising enterocolitis.
Article
We studied the occurrence of necrotizing enterocolitis in 2681 very low birth weight infants during an 18-month period to characterize the biodemographic and clinical correlates. Proven necrotizing enterocolitis (Bell stage II and beyond) occurred in 10.1% of study infants; necrotizing enterocolitis was suspected in 17.2% of study infants. Positivity of blood cultures was related to necrotizing enterocolitis staging. The mortality rate increased only for stage III necrotizing enterocolitis (54% died). Logistic regression identified medical center of birth, race, gender, birth weight, maternal hemorrhage, duration of ruptured membranes, and cesarean section as significant risk factors. For one center the odds ratio was 3.7, whereas for another center it was only 0.3. For black boys, the odds ratio was 2.3 relative to nonblack boys; for girls, race did not affect prevalence of necrotizing enterocolitis. Age at onset was related to birth weight and gestational age. Intercenter differences in necrotizing enterocolitis prevalence were related to time required to regain birth weight and other indicators of fluid management. Gram-positive organisms predominated in positive blood cultures for stage I and II necrotizing enterocolitis; enteric bacteria were isolated more frequently in infants with stage III disease. We conclude that necrotizing enterocolitis prevalence varies greatly among centers; this may be related to early clinical practices of neonatal care.
Article
In a prospective multicentre study on 926 preterm infants formally assigned to their early diet, necrotising enterocolitis developed in 51 (5.5%). Mortality was 26% in stringently confirmed cases. In exclusively formula-fed babies confirmed disease was 6-10 times more common than in those fed breast milk alone and 3 times more common than in those who received formula plus breast milk. Pasteurised donor milk seemed to be as protective as raw maternal milk. Among babies born at more than 30 weeks' gestation confirmed necrotising enterocolitis was rare in those whose diet included breast milk; it was 20 times more common in those fed formula only. Other risk factors included very low gestational age, respiratory disease, umbilical artery catheterisation, and polycythaemia. In formula-fed but not breast-milk-fed infants, delayed enteral feeding was associated with a lower frequency of necrotising enterocolitis. With the fall in the use of breast milk in British neonatal units, exclusive formula feeding could account for an estimated 500 extra cases of necrotising enterocolitis each year. About 100 of these infants would die.
Article
To test the hypothesis that delayed oral feedings would lower the incidence of necrotizing enterocolitis (NEC) in neonates weighing less than 1,500 g at birth, we compared the incidence of NEC in two matched groups of newborns. High-risk neonates were selected from 160 consecutive admissions, based on a cumulative risk scoring of their illness during the first three days of life. One group (N = 20) was given no oral feedings for two weeks, receiving nutrition parenterally, while the other (N = 18) was given incremental enteric feedings of dilute infant formula or breast milk during the first two weeks of life. The overall incidence of NEC in the parenterally fed group was 60% (12/20) compared with 22% (4/18) in the early-oral-feeding group. These data show that withholding oral feedings for two weeks postnatally does not lower the incidence of NEC and in fact may promote its occurrence.
Article
The effects of neonatal illness and caloric intake on head growth velocity and on 1-year developmental outcome were studied in 73 appropriate (AGA) and small for gestational age (SGA) premature infants of (mean +/- SD) 30 +/- 2 weeks gestation who received intensive care during the neonatal period. Head growth from birth to 1 year of corrected age was characterized by a triphasic curve initiated by a period of growth arrest or suboptimal growth followed by a period of catch-up growth and terminated by a period of growth along standard curves. Head growth arrest or suboptimal head growth were directly related to the duration of the initial period of caloric deprivation (less than 85 kcal/kg/day) and to the duration of mechanical ventilation. Catch-up head growth was influenced by the duration of the preceding period of caloric deprivation in all infants and by the caloric intake during that phase only in SGA infants; catch-up growth was unrelated to the duration of mechanical ventilation. Head growth along standard curves occurred in all infants by 3 months of corrected age and persisted up to 1 year of corrected age. Infants calorically deprived the longest (AGA 4 to 6 weeks, SGA 2 to 3 weeks) had head growth along standards at curves below -1 SD on the growth chart; all other groups had this phase of head growth at curves between the mean and -1 SD. Infants calorically deprived for more than 4 weeks had developmental scores below normal ranges by 1 year of corrected age.
Article
A comparison has been made of the influence of feeding own mother's milk and formula on the oxidation and accretion of energy and macronutrients in the growing preterm infant of very low birth weight (less than 1,300 g) by using the combined techniques of nutrient balance and computerized indirect calorimetry. There were 22 studies in formula-fed infants and 15 studies in premature infants fed own mother's milk. Despite their lower metabolizable energy intake, the infants fed own mother's milk grew in weight, length, and head circumference at a rate approximating those of the formula-fed group. The metabolic rate was significantly lower in the infants fed own mother's milk (56.0 +/- 0.9 v 62.6 +/- 0.8 kcal/kg/d; P less than .001). The protein intake, oxidation, and accretion were similar in the two groups. The infants fed own mother's milk had a significantly lower fat intake (P less than .001), higher fat oxidation (P less than .025) and consequently lower fat accretion (P less than .001) than the formula-fed infants. The proportional fat content of the daily weight gain was lower in the infants fed own mother's milk (16% v 33%; P less than .001) but protein content was similar (13% v 12%). The accretion of energy, fat, and protein correlated with the respective metabolizable intakes in both groups (r = .81 to .98; P less than .001), suggesting that accretion rates and hence composition of weight gain are dependent on levels of energy and macronutrient intake.
Article
An abundant amino acid in the human body, glutamine (Gln) has many important metabolic roles that may protect or promote tissue integrity and enhance the immune system. Low plasma and tissue levels of Gln in the critically ill suggest that demand may exceed endogenous supply. A relative deficiency of Gln in such patients could compromise recovery and result in prolonged illness and an increase in late mortality. This study examines this hypothesis. Using a prospective, block-randomized, double-blind treatment study design, we tested whether a Gln-containing parenteral nutrition (PN) compared with an isonitrogenous, isoenergetic control feed would influence outcome, with the endpoints of morbidity, mortality, and cost at 6 mo postintervention. In one general intensive care unit (ICU), to ensure consistency of management policies, 84 critically ill adult patients, with Acute Physiological and Chronic Health Evaluation II score > 10, requiring nutritional support received PN only if enteral nutrition was contraindicated or unsuccessful. Survival at 6 mo was significantly improved in those receiving Gln PN (24/42 versus 14/42; P = 0.049). Significantly more deaths occurred in patients requiring control PN for > 10 d (P = 0.03). The excess control deaths occurred later and those patients had had a significantly longer postintervention stay (P = 0.012) and use of ICU. In the Gln recipients, the total ICU and hospital cost per survivor was reduced by 50%. In critically ill ICU patients unable to receive enteral nutrition, a Gln-containing PN solution improves survival at 6 mo and reduces the hospital costs per survivor.
Article
We have become accustomed to the idea that the major disorders of adult life, including coronary heart disease, stroke and diabetes, arise from an interaction between influences in our adult lifestyle and a genetically determined susceptibility. Recent research, however, suggests that growth in utero may also play an important role.
Article
Necrotizing enterocolitis (NEC) has been documented in up to 20% of infants after repair of gastroschisis and is responsible for significant morbidity. NEC is reported to occur up to 10 times more in preterm infants receiving standard formula compared with those who have been fed exclusively with breast milk. Does breast milk confer a similar protection against NEC in infants who have undergone surgery for gastroschisis? All newborns with gastroschisis delivered between 1990 and 1996 and treated in a single neonatal unit were analyzed retrospectively. Clinical data, details of feeding regimens, and episodes of definite NEC were recorded. Of 60 infants with gastroschisis, 6 (10%) died but none had evidence of NEC. Of the remaining 54 infants, clinical and radiological signs of NEC developed in 8 (15%). All recovered with medical treatment including the three patients with recurrent episodes. NEC developed in none of the 12 babies exclusively fed with expressed breast milk (EBM) in contrast to 1 (5%) of the 19 who received both EBM and formula, and 7 (30%) of the 23 who were fed solely on formula. There was no significant difference in gestation, incidence of primary versus silo closure, or incidence of intestinal atresia/stenosis in those with NEC (n=8) compared with those without (n=46), but birth weight in the NEC group was lower. NEC was less likely to develop in infants who received EBM than those who were exclusively formula fed (P < .02). After gastroschisis repair, feeding with maternal expressed breast milk may help to protect the infant from developing NEC.
Article
Our previous studies raised two hypotheses: first that suboptimal early nutrition and second that human milk have enhancing effects on long-term bone mineralization. To test these hypotheses experimentally, we measured whole body and regional bone mineral content (BMC) and bone mineral density (BMD), using dual-energy X-ray absorptiometry and single-photon absorptiometry, and bone turnover at 8-12 years in 244 preterm children (128 boys) who participated in a prospective randomized study of diet during the neonatal period. Dietary randomizations studied were: banked human milk (BBM, n = 87) versus preterm formula (PTF, n = 96) as the sole diet or as a supplement to mother's expressed breast milk (EBM); PTF (n = 25) versus term formula (TF, n = 36) as sole diet. Ninety-five term children of the same age were also studied. First, preterm children were shorter and lighter than term children (height SD scores -0.49 (1.1) vs. +0.22 (0.9), weight SD scores -0.41 (1.2) vs. +0.38 (1.0)) and had significantly lower whole-body BMC than their peers; decrements were also evident at some regional sites. These differences disappeared after adjusting for bone area, body size, and pubertal status. Second, children previously randomized to BBM versus PTF or TF versus PTF showed no significant differences in anthropometry, BMC, BMD, or osteocalcin (OC). Third, there was no independent effect of the proportion of EBM on BMC, BMD, or OC and no interaction between randomized diet and the amount of EBM received. Fourth, plasma OC was significantly higher in preterm children than in term children (12.4 vs. 11.0 ng/ml, p < 0.005) and in preterm children who had received a low-nutrient (BBM/TF) as opposed to a high-nutrient diet (PTF) during the neonatal period (12. 9 vs. 11.9 ng/ml, p = 0.03). In conclusion, preterm children are shorter, lighter, and have lower bone mass than their peers at age 8-12 years. The lower BMC is, however, appropriate for the bone and body size achieved. Despite large differences in early mineral intake, early diet does not affect bone mass in preterm children, and fresh human milk has no specific effect. However, poor nutrition during the neonatal period may result in higher bone formation rates during childhood.
Article
The hypothesis that adult disease has fetal origins is plausible, but much supportive evidence is flawed by incomplete and incorrect statistical interpretation. When size in early life is related to later health outcomes only after adjustment for current size, it is probably the change in size between these points (postnatal centile crossing) rather than fetal biology that is implicated. Even when birth size is directly related to later outcome, some studies fail to explore whether this is partly or wholly explained by postnatal rather that prenatal factors. These considerations are critical to understanding the biology and timing of 'programming,' the direction of future research, and future public health interventions.
Article
Parenteral nutrition is commonly given in the newborn period to premature infants or those with gastrointestinal disorders. Computer-assisted prescribing is widely used, with prescriptions for each patient being varied on a daily basis. It has previously been suggested that 'individualization' of feeds may have little clinical benefit whilst increasing pharmacy workload and costs. However, the scope for use of standard feed solutions as an alternative remains uncertain. To assess the potential for using standardized pre-mixed feeds we prospectively reviewed 148 computer assisted prescriptions for newborn infants in order to establish how often the prescribing clinician adhered to the computer protocol, and the reason for modification when this occurred. Only one-fifth of feeds were based strictly on the computer recommendation with no, or minimal, modification. However, many of the deviations in the other four-fifths of feed prescriptions reflected a routine use of higher carbohydrate, sodium and phosphate intakes implying that a higher proportion of feeds could be 'standardized' if the computer regimens were modified to reflect current nutritional practices on the unit. This study suggests that the introduction of standard PN feeds could considerably reduce the use of computer assisted individualized PN prescriptions on the neonatal unit. The practical implications of such a system for pharmacy and the potential cost benefits deserve further investigation.
Article
To determine the effect of trophic feeding on clinical outcome in ill preterm infants. A randomised, controlled, prospective study of 100 preterm infants, weighing less than 1750 g at birth and requiring ventilatory support and parenteral nutrition, was performed. Group TF (48 infants) received trophic feeding from day 3 (0.5-1 ml/h) along with parenteral nutrition until ventilatory support finished. Group C (52 infants) received parenteral nutrition alone. "Nutritive" milk feeding was then introduced to both groups. Clinical outcomes measured included total energy intake and growth over the first six postnatal weeks, sepsis incidence, liver function, milk tolerance, duration of respiratory support, duration of hospital stay and complication incidence. Groups were well matched for birthweight, gestation and CRIB scores. Infants in group TF had significantly greater energy intake, mean difference 41.4 (95% confidence interval 9, 73.7) kcal/kg p=0.02; weight gain, 130 (CI 1, 250) g p = 0.02; head circumference gain, mean difference 0.7 (CI 0.1, 1.3) cm, p = 0.04; fewer episodes of culture confirmed sepsis, mean difference -0.7 (-1.3, -0.2) episodes, p = 0.04; less parenteral nutrition, mean difference -11.5 (CI -20, -3) days, p = 0. 03; tolerated full milk feeds (165 ml/kg/day) earlier, mean difference -11.2 (CI -19, -3) days, p = 0.03; reduced requirement for supplemental oxygen, mean difference -22.4 (CI-41.5, -3.3) days, p = 0.02; and were discharged home earlier, mean difference -22.1 (CI -42.1, -2.2) days, p = 0.04. There was no significant difference in the relative risk of any complication. Trophic feeding improves clinical outcome in ill preterm infants requiring parenteral nutrition.
Article
Environmental factors, nutritional supplies, hormonal status, diseases, and treatments appear to affect postnatal skeletal growth and mineralization in VLBW infants. Compared with their term counterparts, ELBW infants are at risk of postnatal growth deficiency and osteopenia at the time of hospital discharge. From recent data, DXA is becoming one of the reference techniques to evaluate mineral status, whole-body composition, and effects of dietary manipulations on weight gain composition and mineral accretion in preterm infants. Weight gain and length increases need to be evaluated carefully during the first weeks of life, in the intensive care unit and out of it, in the step down unit. Nutritional survey is required to improve the nutritional supply and to maximize linear growth. As the critical epoch of growth extends, during the first weeks or months after discharge, follow-up and nutritional support need to be provided during the first years to promote early catch-up growth and mineralization. Further studies need to determine precisely the most optimal feeding regimen during this period but also need to evaluate the long-term implications of such a policy on stature, peak bone mass, and general health at adulthood.
Article
Whole body composition was investigated using dual energy x-ray absorptiometry in 54 healthy preterm infants, birth weight < 1750 g, who were fed fortified human milk (n = 20) and preterm formula (n = 34) when full enteral feeding was attained and then again 3 wk later at around the time of discharge. Weight gain composition was calculated from the difference between the earlier and later measurement. The minimal detectable changes in whole body composition over time according to the variance of the population (within groups of 20 infants) and the minimal detectable changes according to the dietary intervention (between two groups of 20 infants) were determined at 5% significance and 80% power. Whole body composition was similar in the two groups at the initial measurement, but all the measured variables differed at the time of the second measurement. Formula-fed infants showed a greater weight gain (19.9 +/- 3.2 versus 15.9 +/- 2.2 g.kg(-1).d(-1), p < 0.05), fat mass deposition (5.1 +/- 1.9 versus 3.3 +/- 1.3 g.kg(-1).d(-1), p < 0.05), bone mineral content gain (289 +/- 99 versus 214 +/- 64 mg.kg(-1).d(-1), p < 0.05), and increase in bone area (1.6 +/- 0.4 versus 1.3 +/- 0.3 cm(2).kg(-1).d(-1), p < 0.05) compared with the fortified human milk group. From these data, a minimal increase from the first measurement of 111 g lean body mass, 68 g fat mass, and 3. 1 g bone mineral content is needed to be detectable in a longitudinal study that includes 20 infants. For significance between two groups of 20 infants around the time of discharge, dietary intervention needs to achieve minimal differences of 160 g lean body mass, 86 g fat mass, and 4.1 g bone mineral content. With respect to weight gain composition, the minimal differences required to reach significance are 2.1 g.kg(-1).d(-1) for gain in lean body mass, 1.2 g.kg(-1).d(-1) for gain in fat mass, and 76 mg.kg(-1). d(-1) for gain in bone mineral content. We conclude that dual energy x-ray absorptiometry allows evaluation of the effects of dietary intervention on whole body and weight gain composition in preterm infants during the first weeks of life.
Article
We have shown that preterm infants fed a preterm formula grow better than those fed a standard term infant formula after hospital discharge. The purpose of this follow-up study was to determine whether improved early growth was associated with later growth and development. Preterm infants (< or =1750 g birth weight, < or =34 wk gestation) were randomized to be fed either a preterm infant formula (discharge to 6 mo corrected age), or a term formula (discharge to 6 mo), or the preterm (discharge to term) and the term formula (term to 6 mo). Anthropometry was performed at 12 wk and 6, 12, and 18 mo. Mental and psychomotor development were assessed using the Bayley Scales of Infant Development II at 18 mo. Differences in growth observed at 12 wk were maintained at 18 mo. At 18 mo, boys fed the preterm formula were 1.0 kg heavier, 2 cm longer, and had a 1.0 cm greater occipitofrontal circumference than boys fed the term formula. Boys fed the preterm formula were also 600 g heavier and 2 cm longer than girls fed the preterm formula. However, no differences were noted in MDI or PDI between boys fed the preterm formula and boys fed the term formula or between the boys fed preterm formula and girls fed the preterm formula. Overall, boys had significantly lower MDI than girls (mean difference, 6.0; p < 0.01), primarily reflecting lower scores in boys fed the term formula. Thus, early diet has long-term effects on growth but not development at 18 mo of age. Sex remains an important confounding variable when assessing growth and developmental outcome in these high-risk infants.
Article
Substitutes for breast milk for young infants have been developed from the milk of other mammals, through a variety of modifications, into the complex formulas that are available today. These developments resulted from improvements in the understanding of the chemical and nutrient composition of human milk and mammalian milks in general. Initially, the sole criterion for the ad-equacy of such formulas was the survival of infants fed on them. Subsequently, as the products became more refined, and their gross composition was modified to resemble more closely that of human milk, other factors such as linear and ponderal growth of the babies, and other anthropometric, biochemical, and metabolic factors were included in the evaluation of their effects (1). These criteria have often been measured over short periods of time (e.g., 1 to 3 months). However, it is now appreciated that early infant feeding may influence growth, develop-ment, and the incidence of gastrointestinal, respiratory, and allergic disease in early childhood (2–4) and, possi-bly, metabolism and health in later childhood and adult-hood (4–8). Consequently, the nature of the evaluation of infant formulas and breast milk substitutes needs to be reviewed, focusing also on longer term nutritional and safety outcomes. The aim of this paper is to highlight the need for a systematic evaluation of nutritional and safety characteristics of dietary products for use in infants (e.g., infant formulas, follow-on formulas, dietary products for infants that are marketed as Foods for Special Medical Purposes [9] and other dietetic products for infants such as complementary foods). However, the Committee ac-knowledges that different criteria for nutritional and safety characterization may apply for products used as the sole and predominant food source, such as infant formulas and some Foods for Special Medical Purposes that are used as substitutes for breast milk or formula, compared with products that comprise only a minor por-tion of the total dietary intake, such as some complemen-tary food. Formulas are regarded as products intended to satisfy totally the nutritional requirements of infants during the first 4 to 6 months of life, and to contribute a major part of the nutritional requirements throughout the first year of life. The Directive on Infant Formulae and Follow on Formulae, published in 1991 (10), defines their basic composition, and it also permitted member states of the European Union to submit proposals for amendments to the composition of infant formulas. Since then, the in-clusion of nucleotides, selenium, phospholipids, and long-chain polyunsaturated fatty acids has been allowed. Recently, a review of the evaluation of infant formulas was undertaken by a working group of the Committee on Medical Aspects of Food and Nutrition Policy of En-gland and Wales (11). The Committee on Nutrition supports the general con-cepts outlined in the report of the Committee on Medical Aspects of Food and Nutrition Policy of England and Wales, and agrees the following recommendations and comments are particularly important.
Article
Carbohydrate and fat may vary in their ability to support protein accretion and growth. If so, variations in the source of nonprotein energy might be used to therapeutic advantage in enterally fed low-birth-weight infants. To test the hypothesis that high-carbohydrate diets are more effective than isocaloric high-fat diets in promoting growth and protein accretion, low-birth-weight infants weighing 750-1600 g at birth were randomized in a double blind study to receive one of five formulas differing only in the quantity and quality of nonprotein energy. Groups 1, 2, and control received 130 kcal x kg(-1) x d(-1) with 35, 65, and 50% of the nonprotein energy as carbohydrate. Groups 3 and 4 received energy intake of 155 kcal x kg(-1) x d(-1) with 35 and 65% of the nonprotein energy as carbohydrate. Protein intake of all groups was 4 g x kg(-1) x d(-1). Growth and metabolic responses were followed weekly, and macronutrient balances including 6-h indirect calorimetry were performed biweekly. Greater rates of weight gain and nitrogen retention were observed at high-carbohydrate intake compared with high-fat intake at both gross energy intakes. Greater rates of energy storage and an increase in skinfold thickness were observed in group 4 (high-energy high-carbohydrate diet) despite higher rates of energy expenditure. These data support the hypothesis that at isocaloric intakes, carbohydrate is more effective than fat in enhancing growth and protein accretion in enterally fed low-birth-weight infants. However, a diet with high-energy and high-carbohydrate content also results in increased fat deposition.
Article
In recent years, improvements in care have significantly improved survival in preterm and, particularily, the very low birth weight infant (VLBW). While immediate survival can be directly related to pulmonary maturity, several studies stress the importance of timely and adequate nutrition in these high-risk infants on a short- and long-term [1]. Yet, nutritional support remains a very controversial issue in these high-risk infants. Early provision of adequate intakes may be limited by clinical instability and immaturity. At the same time, nutritional requirements and methods of nutritional assessment are not well defined. The aim of this paper is to outline some of the methods used during nutritional assessment in preterm infants with special reference to the measurement of body composition.