Barbara E. Cormack

The importance of early complementary feeding in the development of oral tolerance: concerns and controversies.

Rising rates of food allergies in early childhood reflect increasing failure of early immune tolerance mechanisms. There is mounting concern that the current recommended practice of delaying complementary foods until 6 months of age may increase, rather than decrease, the risk of immune disorders. Tolerance to food allergens appears to be driven by regular, early exposure to these proteins during a ‘critical early window’ of development. Although the timing of this window is not clear in humans, current evidence suggests that this is most likely to be between 4 and 6 months of life and that delayed exposure beyond this period may increase the risk of food allergy, coeliac disease and islet cell autoimmunity. There is also evidence that other factors such as favourable colonization and continued breastfeeding promote tolerance and have protective effects during this period when complementary feeding is initiated. This discussion paper explores the basis for concern over the current recommendation to delay complementary foods as an approach to preventing allergic disease. It will also examine the growing case for introducing complementary foods from around 4 months of age and maintaining breastfeeding during this early feeding period, for at least 6 months if possible.

Increased protein intake decreases postnatal growth faltering in ELBW babies

Objective To determine whether purposely designed nutritional guidelines for extremely low birthweight (ELBW; birth weight <1000 g) babies result in protein intakes that meet international consensus recommendations, and whether this results in improved growth from birth to discharge. Design A prospective cohort study of nutritional intakes and growth in ELBW babies. Setting A tertiary neonatal intensive care unit in New Zealand. Patients 100 ELBW babies who survived for the first month of life, 50 before the introduction of the guideline (Lo Pro) and 50 after (Hi Pro). Intervention Introduction of a nutritional guideline aimed at increasing protein intakes to meet international consensus recommendations. Main outcome measures Weekly protein intakes over the first month of life and growth until discharge. Results Hi Pro babies had significantly higher protein intakes in the first month of life than Lo Pro babies (mean (SD), 3.8 (0.3) vs 3.3 (0.4) g/kg.day, p<0.0001) and a significantly greater growth velocity (GV) over the first 30 days after regaining birth weight (19.5 (5.0) vs 16.2 (5.4) g/kg.day, p<0.002). Hi Pro babies had a significantly lesser Z-score change between birth and discharge than Lo Pro babies for weight (0.0 (1.2) vs −0.9 (1.1), p=0.001), length (−0.8 (0.8) vs −1.2 (1.1), p=0.02) and head circumference (−0.2 (1.1) vs −1.1 (1.6), p<0.001). Conclusions Simple, standardised nutritional guidelines can result in recommended protein intakes for ELBW babies being achieved and result in increased GV. Downward crossing of centiles between birth and discharge, common in ELBW babies, is significantly reduced for weight, length and head circumference.

Audit of feeding practices in babies <1200 g or 30 weeks gestation during the first month of life

Aim:  In 2002, the composition of the breast milk fortifier used in our hospital changed, giving increased protein and energy. We therefore decided to prospectively audit nutritional management in our unit and to compare nutritional intake and growth in our babies with published data.

Does more protein in the first week of life change outcomes for very low birthweight babies

Background:  Following publication of revised recommended nutrient intakes (RNI) for infants <1500 g, our intravenous nutrition (IVN) solutions were reformulated to deliver RNI in a restricted volume to ensure additional non‐nutritional fluids did not detract from nutritional intake. An audit was performed to determine whether these changes achieved RNI and influenced growth, clinical or neurodevelopmental outcomes.

Comparing apples with apples: it is time for standardized reporting of neonatal nutrition and growth studies.

The ultimate goal of neonatal nutrition care is optimal growth, neurodevelopment, and long-term health for preterm babies. International consensus is that increased energy and protein intakes in the neonatal period improve growth and neurodevelopment, but after more than 100 y of research the optimum intakes of energy and protein remain unknown. We suggest an important factor contributing to the lack of progress is the lack of a standardized approach to reporting nutritional intake data and growth in the neonatal literature. We reviewed randomized controlled trials and observational studies documented in MEDLINE and the Web of Science from 2008 to 2015 that compared approximately 3 vs. 4 g.kg–1.d–1 protein for preterm babies in the first month after birth. Consistency might be expected in the calculation of nutritional intake and assessment of growth outcomes in this relatively narrow scope of neonatal nutrition research. Twenty-two studies were reviewed. There was substantial variation in methods used to estimate and calculate nutritional intakes and in the approaches used in reporting these intakes and measures of infant growth. Such variability makes comparisons amongst studies difficult and meta-analysis unreliable. We propose the StRONNG Checklist—Standardized Reporting Of Neonatal Nutrition and Growth to address these issues.

Severe Hyperemesis Gravidarum Is Associated With Reduced Insulin Sensitivity in the Offspring in Childhood

BACKGROUND Hyperemesis gravidarum alters maternal (and possibly fetal) nutrition throughout pregnancy, but there are no data on long-term effects on offspring metabolism. Thus, we aimed to assess whether severe hyperemesis gravidarum (SHG) affects glucose homeostasis and body composition in the offspring in childhood. METHODS Healthy prepubertal children (aged 4-11 years) born at term were studied: offspring of mothers who were admitted to hospital with SHG (n = 36) and offspring of mothers from control pregnancies (n = 42). Primary outcome was insulin sensitivity measured using iv glucose tolerance tests and Bergmans minimal model. Other assessments included lipid and hormonal profiles and body composition using whole-body dual-energy x-ray absorptiometry. RESULTS Insulin sensitivity in SHG children was 20% lower than in controls (8.49 vs 10.60 × 10(-4)·min(-1)·(mU/L); P = .014). SHG children also had higher fasting insulin (6.88 vs 5.04 mIU/L; P = .024) and lower IGF binding protein 1 (11.8 vs 19.0 ng/mL; P = .004) concentrations than controls. Baseline cortisol concentrations were 22% higher in SHG offspring (256 vs 210 nmol/L; P = .021). Children in both groups were anthropometrically similar. CONCLUSION Children born to mothers who experienced SHG have lower insulin sensitivity, which may increase their long-term risk of developing diabetes mellitus. Follow-up of SHG offspring is essential to determine later risk of metabolic disease.

Advances in nutrition of the newborn infant

Nutrition of newborn infants, particularly of those born preterm, has advanced substantially in recent years. Extremely preterm infants have high nutrient demands that are challenging to meet, such that growth faltering is common. Inadequate growth is associated with poor neurodevelopmental outcomes, and although improved early growth is associated with better cognitive outcomes, there might be a trade-off in terms of worse metabolic outcomes, although the contribution of early nutrition to these associations is not established. New developments include recommendations to increase protein supply, improve formulations of parenteral lipids, and provide mineral supplements while encouraging human milk feeding. However, high quality evidence of the risks and benefits of these developments is lacking. Clinical trials are also needed to assess the effect on preterm infants of experiencing the smell and taste of milk, to determine whether boys and girls should be fed differently, and to test effects of insulin and IGF-1 supplements on growth and developmental outcomes. Moderate-to-late preterm infants have neonatal nutritional challenges that are similar to those infants born at earlier gestations, but even less high quality evidence exists upon which to base clinical decisions. The focus of research in nutrition of infants born at term is largely directed at new formula products that will improve cognitive and metabolic outcomes. Providing the most effective nutrition to preterm infants should be prioritised as an important focus of neonatal care research to improve long-term metabolic and developmental outcomes.

Do recommended protein intakes improve neurodevelopment in extremely preterm babies

Objective To determine whether achieving recommended protein intakes for extremely low birthweight (ELBW; birth weight <1000 g) babies, resulting in better growth, improves neurodevelopmental outcomes. Design A prospective cohort study of ELBW babies before and after the introduction of a new nutritional policy designed to meet international consensus protein recommendations. Forty-five children born ‘before’ and 42 born ‘after’ the policy change were assessed at 2 years’ corrected age (CA). Associations between nutritional intakes, growth and neurodevelopmental outcome (Bayley Scales of Infant and Toddler Development, Third edition (Bayley-III), motor and sensory impairment) were assessed using univariate and multivariate analyses. Results Bayley-III cognitive (mean (SD) 96 (12) vs 96 (15)), motor (96 (13) vs 95 (15)) or language scores (89 (11) vs 91 (17)) were not different between the ‘before’ and ‘after’ cohorts. In the ‘before’ cohort, motor scores were positively associated with enteral nutrition intakes and growth velocity. Neither were sensory impairments different between groups (visual impairment 4 vs 2, hearing impairment 2 vs 0) nor was the gross motor function classification score (any cerebral palsy 2 vs 1). Conclusions In this prospective cohort study, increasing intravenous and enteral protein intakes to recommended levels in the first month after birth was not associated with improved cognitive, language or motor scores or decreased sensory impairments at 2 years’ CA despite significantly improved early growth and reduced postnatal faltering growth. Appropriate randomised controlled trials are needed to answer definitively whether higher early protein intakes improve neurodevelopmental outcome in this population.

Australasian neonatal intensive care enteral nutrition survey: Implications for practice

This survey investigated standardised feeding guidelines and nutrition policy in Australasian neonatal intensive care units and compared these with previously published surveys and international consensus nutrition recommendations.

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

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