Alison A. Leaf

Preterm Birth and Body Composition at Term Equivalent Age: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVE: Infants born preterm are significantly lighter and shorter on reaching term equivalent age (TEA) than are those born at term, but the relation with body composition is less clear. We conducted a systematic review to assess the body composition at TEA of infants born preterm. METHODS: The databases MEDLINE, Embase, CINAHL, HMIC, “Web of Science,” and “CSA Conference Papers Index” were searched between 1947 and June 2011, with selective citation and reference searching. Included studies had to have directly compared measures of body composition at TEA in preterm infants and infants born full-term. Data on body composition, anthropometry, and birth details were extracted from each article. RESULTS: Eight studies (733 infants) fulfilled the inclusion criteria. Mean gestational age and weight at birth were 30.0 weeks and 1.18 kg in the preterm group and 39.6 weeks and 3.41 kg in the term group, respectively. Meta-analysis showed that the preterm infants had a greater percentage total body fat at TEA than those born full-term (mean difference, 3%; P = .03), less fat mass (mean difference, 50 g; P = .03), and much less fat-free mass (mean difference, 460 g; P < .0001). CONCLUSIONS: The body composition at TEA of infants born preterm is different than that of infants born at term. Preterm infants have less lean tissue but more similar fat mass. There is a need to determine whether improved nutritional management can enhance lean tissue acquisition, which indicates a need for measures of body composition in addition to routine anthropometry.

Early parenteral nutrition and growth outcomes in preterm infants: a systematic review and meta-analysis

BACKGROUND The achievement of adequate nutritional intakes in preterm infants is challenging and may explain the poor growth often seen in this group. The use of early parenteral nutrition (PN) is one potential strategy to address this problem, although the benefits and harms are unknown. OBJECTIVE We determined whether earlier administration of PN benefits growth outcomes in preterm infants. DESIGN We conducted a systematic review of randomized controlled trials (RCTs) and observational studies. RESULTS Eight RCTs and 13 observational studies met the inclusion criteria (n = 553 and 1796 infants). The meta-analysis was limited by disparate growth-outcome measures. An assessment of bias was difficult because of inadequate reporting. Results are given as mean differences (95% CIs). Early PN reduced the time to regain birth weight by 2.2 d (1.1, 3.2 d) for RCTs and 3.2 d (2.0, 4.4 d) in observational studies. The maximum percentage weight loss with early PN was lower by 3.1 percentage points (1.7, 4.5 percentage points) for RCTs and by 3.5 percentage points (2.6, 4.3 percentage points) for observational studies. Early PN improved weight at discharge or 36 wk postmenstrual age by 14.9 g (5.3, 24.5 g) (observational studies only), but no benefit was shown for length or head circumference. There was no evidence that early PN significantly affects risk of mortality, necrotizing enterocolitis, sepsis, chronic lung disease, intraventricular hemorrhage, or cholestasis. CONCLUSIONS The results of this review, although subject to some limitations, show that early PN provides a benefit for some short-term growth outcomes. No evidence that early PN increases morbidity or mortality was found. Neonatal research would benefit from the development of a set of core growth outcome measures.

Strategies for getting preterm infants home earlier

Neonatal intensive and special care is an expensive and limited health resource. Having a child in hospital is stressful and inconvenient for families, and may result in unbudgeted costs and loss of income; the home environment is most appropriate for normal infant development. For these reasons it is important that babies are discharged from neonatal units as early as is safely possible. Preterm infants take up the majority of neonatal hospital bed-days and our review will focus on this population. There are three main parameters to consider: physiological maturity, parental readiness and home environment, and administrative/bureaucratic infrastructure. In a critical review of early discharge from the neonatal intensive care unit (NICU) for very-low-birthweight (VLBW) infants, Merritt et al 1 summarised what has previously been published about discharge criteria. For physiological maturity, most would agree that adequate suckling to maintain weight gain, respiratory stability with freedom from apnoea, and ability to maintain body temperature in an open cot are important criteria. Despite this general consensus, there is marked variation in length of stay: the average for babies <1.5 kg birth weight discharged home from the 552 hospitals participating in the Vermont Oxford Database in 2005 ranged from ∼40 to ∼80 days (fig 1). Some of this variation reflects different gestational age distribution (fig 2) and some reflects differences in diagnoses and clinical outcomes—for example, chronic lung disease, necrotising enterocolitis requiring surgery, and more than two episodes of sepsis are associated with prolonged hospital stays.2 Some variation is due to different management policies for clinical issues such as apnoea and infant feeding.3 However, differences in the discharge process may also be important, as illustrated by the finding that moderately preterm infants cared for in the Kaiser Permanente Medical Care Program in California were discharged on average 4 days younger than …

Nutrition and neurodevelopmental outcomes in preterm infants: a systematic review

A systematic review with meta‐analysis was carried out to investigate the effects of increased nutritional intake, via either macronutrient or multinutrient intervention, during the neonatal period on neurodevelopmental outcomes in infants born at <32 weeks of gestation or weighing <1501 g at birth.

Successfully implementing and embedding guidelines to improve the nutrition and growth of preterm infants in neonatal intensive care: a prospective interventional study

Objectives We aimed to improve the nutritional care of preterm infants by developing a complex (multifaceted) intervention intended to translate current evidence into practice. We used the sociological framework of Normalization Process Theory (NPT), to guide implementation in order to embed the new practices into routine care. Design A prospective interventional study with a before and after methodology. Participants Infants <30 weeks gestation or <1500 g at birth. Setting Tertiary neonatal intensive care unit. Interventions The intervention was introduced in phases: phase A (control period, January–August 2011); phase B (partial implementation; improved parenteral and enteral nutrition solutions, nutrition team, education, August–December 2011); phase C (full implementation; guidelines, screening tool, ‘nurse champions’, January–December 2012); phase D (postimplementation; January–June 2013). Bimonthly audits and staff NPT questionnaires were used to measure guideline compliance and ‘normalisation’, respectively. NPT Scores were used to guide implementation in real time. Data on nutrient intakes and growth were collected continuously. Results There were 52, 36, 75 and 35 infants in phases A, B, C and D, respectively. Mean guideline compliance exceeded 75% throughout the intervention period, peaking at 85%. Guideline compliance and NPT scores both increased over time, (r=0.92 and 0.15, p<0.03 for both), with a significant linear association between the two (r=0.21, p<0.01). There were significant improvements in daily protein intake and weight gain between birth and discharge in phases B and Ccompared with phase A (p<0.01 for all), which were sustained into phase D. Conclusions NPT and audit results suggest that the intervention was rapidly incorporated into practice, with high guideline compliance and accompanying improvements in protein intake and weight gain. NPT appears to offer an effective way of implementing new practices such that they lead to sustained changes in care. Complex interventions based on current evidence can improve both practice and clinical outcomes.

Suboptimal nutrition in moderately preterm infants

It is recognised that very preterm infants are at risk of later morbidity, including neurodevelopmental impairment (1), respiratory complications and poor growth (2). However, there is increasing evidence that infants born at later preterm gestations are also at greater risk of such adverse outcomes (3,4), with amalgamated data from follow-up studies showing continuous improvement in IQ scores and decreasing risk of respiratory disease as gestational age at birth increases (5). Moderately preterm infants (32–-34 weeks’ gestation) are at increased risk of respiratory distress syndrome (RDS), sepsis, hypothermia, hypoglycaemia, jaundice and feeding difficulties (6) and account for a high proportion of neonatal unit admissions. Post-discharge, they aremore likely to be rehospitalised with jaundice and feeding difficulties (7). Given that preterm infants are deprived of the rapid intrauterinenutrient accretion and growth that occurs during the third trimester, nutritional factors may influence outcomes, and there is evidence that moderate and late preterm infants experience poor growth in the neonatal period (8). While there are published recommendations for the nutrient requirements of very preterm infants (9), the nutritional requirements of moderate and late preterm infants are less established, although guidance for low birthweight infants <2500 g has been published by the World Health Organization (10). Cumulative nutrient deficits are well described in extremely preterm infants, with poor growth and undernutrition associated with adverse outcomes (11). For moderate and late preterm infants, however, there is a paucity of such data. Nutrition can be modified, so represents a potential target for improving outcomes. We aimed to gain a better understanding of nutrition and growth inmoderate and late preterm infants by carrying out a detailed evaluation of the nutritional care of infants born at 32 + 0 to 34 + 6 weeks’ gestation, between January 1, 2012 and June 30, 2012. Infants of more than 35 weeks’ gestation were excluded, as they are not routinely admitted. Data, including pregnancy and neonatal diagnoses, and daily fluid intakes were extracted from infants’ notes. Daily intakes of ninekeynutrients(energy,protein,carbohydrate,fat,calcium, phosphorous,vitaminA,DandE)associatedwithgrowthand bonehealthwere calculated.Weight andhead circumference datawereconvertedtostandarddeviationscores (SDS)based on UK normative data. Differences between groups were compared using Fisher’s exact test (dichotomous outcomes) orANOVA(continuousoutcomes).Therelationshipbetween nutrition, growth and gestation was explored using linear regression (Stata IC v12.1; Stata Corporation 4905, College Station, TX, USA). Ethical approval was not required as this was a service evaluation. Table 1 shows the study population of 54 infants, with clinical characteristics by gestational age. Of these, 52% were delivered by caesarean section, with RDS being the most common neonatal complication. Mean length of stay was 20.5 days and mean post-conceptional age at discharge was 36 + 4 weeks. Approximately one in six (16%) of the infants had intrauterine growth restriction, (IUGR) with a birthweight below the 10th centile, and seven (14%) infants had a birthweight of less than 1500 g. The mean time to regain birthweight was 10.2 days and mean change in weight SDS between birth and discharge was 0.98. Figure 1 demonstrates the nutritional interventions used in each age group. Nine infants received parenteral nutrition (PN) with a mean duration of 12 days. PN use was more common in infants who were more preterm or

How to use: nutritional assessment in neonates

Adequate nutrition and growth during the neonatal period are important, especially for preterm infants, for whom there is evidence of poor nutrient intakes and growth, and this has important implications for their health in later life. Increased nutritional support while on the neonatal intensive care unit has been shown to improve growth, but such support is not universally available. Being able to carry out and interpret a nutritional assessment is therefore an important skill for paediatricians caring for neonates. This article aims to explain how to use nutritional assessment in neonates and provides some tools to make this process as straightforward as possible.

Developing a new screening tool for nutritional risk in neonatal intensive care

1.National Institute for Health Research, Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK 2.Department of Neonatal Medicine, Princess Anne Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK 3.Department of Nutrition and Dietetics, University Hospital Southampton NHS Foundations Trust, Southampton, UK 4.National Institute for Health Research, Southampton Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK

Development of a novel electronic neonatal nutrition assessment tool

Background Poor growth is common in preterm infants in the neonatal period, with poor weight gain, short stature and altered body composition when compared to term infants. Achieving recommended nutrient intakes is difficult; however it is not easy to demonstrate this contemporaneously in routine clinical practice. Methods We developed a customised electronic tool (SENNAT) to capture and analyse growth and nutritional data, with the aim of gaining better understanding of neonatal nutrition at individual and population level. SENNAT uses pre-loaded information on the nutritional content of feeds and fluids to calculate an individuals total daily nutrient intake from daily fluid volumes, and compares these to current recommendations (Tsang 2005). Graphical reports are produced to aid clinical decisions. SENNAT was used to carry out a retrospective review of all infants with a birth weight <1500 g or gestational age at birth <30 weeks, in-born during 2009. Results From 70 eligible infants, case notes were available for 64. Intakes of selected nutrients compared to recommendations for the first week of life through to 36 weeks post conceptual age (PCA) are shown in table 1, together with standard deviation scores (SDS) for weight and head circumference. Figures are mean (SD). Abstract G73 Table 1 Nutrient intakes (as percentage of recommendations) and Growth by week of age Nutrient Week 1 (n=64) Week 2 (n=60) Week 4 (n=50) 36 Weeks PCA (n=37) Energy 84.0 (22.1)* 104.4 (15.7) 98.9 (12.7) 94.2 (16.5)† Protein 42.6 (15.8)* 76.6 (14.5)* 79.8 (17.3)* 83.2 (21.0)* Zinc 114.2 (29.3)* 83.1 (17.9)* 74.2 (20.6)* 87.4 (21.3)* Copper 265.6 (106.4)* 116.0 (37.9)* 87.9 (32.7)† 78.2 (21.0)* Selenium 265.6 (106.4)* 104.8 (9.27)* 98.3 (4.3)* 95.8 (12.2)† Vitamin A 37.6 (17.0)* 83.8 (19.9)* 190.8 (103.9)* 170.7 (69.3)* Vitamin D 55.7 (26.7)* 73.5 (25.8)* 86.3 (31.2)† 96.0 (28.3) Vitamin E 29.8 (16.1)* 60.4 (20.7)* 55.8 (29.7)* 70.8 (29.3)* Vitamin C 30.8 (13.8)* 68.9 (18.2)* 148.2 (86.4)* 146.3 (54.5)* Growth Weight SDS −0.56 (1.18) −1.42 (1.01) −1.35 (0.97) −1.76 (1.03) Head circumference SDS −1.13 (1.27) −1.22 (1.26) −1.7 (1.20) −1.70 (1.29) * p<0.001 and † p<0.05 for difference from recommendations (one-sample t-test). Conclusions Patterns of nutrient intake changed, reflecting periods on parental nutrition, transition to milk feeds and use of nutritional supplements. Intakes of protein were low throughout stay, whilst micronutrient intakes varied. At 36 weeks PCA most intakes were below recommended values and this was reflected in poor growth. We anticipate that modifications to our nutrition policy, combined with weekly assessment using SENNAT, will result in improved nutrient intakes and growth during prospective study in 2012.

5.10 Using detailed clinical nutritional data to predict optimal energy and protein intakes for preterm infants

Background Preterm infants often experience poor growth during the neonatal period, and are discharged with weights and head circumferences on centiles well below that on which they were born. One reason for this is inadequate nutrient provision. Whilst recommendations for nutrient intakes exist, their validity is the subject of debate, and there is a need to better understand optimal nutrient intakes for these infants. Methods Detailed nutrient intake and growth data collected on preterm infants as part of another study was used. Growth was assessed using the difference in standard deviation score (dSDS) for weight and head circumference between birth and discharge. Linear regression of growth and mean intakes of protein and energy during hospital stay was carried out, and optimal intakes were then estimated assuming that ideal growth would result in a dSDS of zero. Results 186 preterm infants were included, with a mean (SD) gestational age and birth weight of 28.6(2.8) weeks and 1.01(0.28)kg. Mean intakes of energy and protein were significantly associated with weight dSDS, with coefficients (95% confidence intervals) of 0.01 (0.001–0.020) and 0.56 (0.307–0.818) respectively. Using regression constants, this equates to estimated optimal intakes of 174 kcal/kg/day and 4.11 g/kg/day protein. However, r 2 values were low at 0.02 and 0.09 respectively. Conclusions This study demonstrates the utility of detailed clinical nutritional data in studying the relationships between intake and growth. Whilst r2 values were low, these findings suggest that energy and protein intakes required for growth along birth centile line may be higher than those currently recommended, and warrant further investigation.