Daniel Virella

Early high calcium and phosphorus intake by parenteral nutrition prevents short-term bone strength decline in preterm infants.

Background and Aim: Very premature newborns have an increased risk of low bone mass and metabolic bone disease. Most longitudinal studies report a significant decline in bone strength in the first weeks after birth. The aim of the study was to evaluate whether higher early calcium (Ca) and phosphorus (P) intake delivered by parenteral nutrition (PN) can prevent bone strength decline in preterm infants, within the first weeks after birth. Patients and Methods: This was a randomized controlled trial of consecutively admitted neonates born with ≤33 weeks of gestational age, assigned to receive either Ca 45 mg · kg−1 · day−1 (low dose [LD]) or Ca 75 mg · kg−1 · day−1 (high dose [HD]) by PN. P was added to the PN solutions at a fixed Ca:P ratio (mg) of 1.7:1. Bone strength was assessed by the speed of sound (SOS) using the quantitative ultrasound method. Measurements were performed weekly from birth until discharge. Low bone strength (SOS <10th centile of reference values) was the main outcome. Results: Eighty-six infants were enrolled, 40 assigned to LD group and 46 to HD group. Mean (standard error) gestational age was 29.6 weeks (2.1) and birth weight was 1262 g (0.356). In the HD group, the SOS values never fell below those recorded at birth and, up to the sixth week of life, low bone strength was significantly less frequent as compared with that in the LD group, in spite of progressive reduction in parenteral mineral intake and/or establishment of full enteral feeding. Conclusions: Early assigned parenteral intake of Ca 75 mg · kg−1 · day−1 and P 44 mg · kg−1 · day−1 significantly contributed to preventing short-term bone strength decline in preterm infants.

A simple equation to estimate the osmolarity of neonatal parenteral nutrition solutions.

UNLABELLED A predictive equation of osmolarity that correlates closely with the measured osmolality was determined. Taking into account that an osmometer is not available in most clinical settings, the proposed equation appears to provide a quick and simple osmolarity calculation of neonatal parenteral nutrition solutions. OBJECTIVE We measured the osmolalities of neonatal parenteral nutrition (PN) solutions to determine if these values may be predicted by a simple equation for calculation of their osmolarity values. METHODS The osmolalities of 101 consecutive different final PN admixtures, prepared for 36 neonates, were measured by the freezing point depression method. The respective intra-assay and interassay coefficients of variation were always <2.1%. Linear multivariate regression analysis was used to determine a predictive equation of osmolarity that correlates closely with the value of measured osmolality. RESULTS The mean (SD) osmolality of the final PN admixtures was 749.7 (165.4) mOsm/kg. The best-fitted equation, with a coefficient of discrimination R2 = .95 (R2 = .90 for samples between 500 and 1000 mOsm/L) is osmolarity (mOsm/L) = (nitrogen x 0.8) + (glucose x 1.235) + (sodium x 2.25) + (phosphorus x 5.43)-50, with the concentration of components in mmol/L. Adapting the equation in our daily practice, using g/L for glucose and amino acids, mg/L for phosphorus, and mEq/L for sodium, the equation is osmolarity (mOsm/L) = (amino acid x 8) + (glucose x 7) + (sodium x 2) + (phosphorus x 0.2) - 50, with a similar R2. CONCLUSIONS Taking into account that an osmometer is not available in most clinical settings, the proposed equation appears to provide a quick and simple osmolarity calculation of neonatal PN solutions, thus allowing more accurate decisions to be taken regarding the choice of route and rate of administration of PN solutions.

Skin conductance indices discriminate nociceptive responses to acute stimuli from different heel prick procedures in infants

Aim: To evaluate the ability of SC indexes in discriminating acute responses to different heel prick procedures. Methods: Observational cohort study of a systematic, convenience sample of neonates with clinical indication of capillary blood sampling by heel prick, either for glycaemia or for blood gas analysis. The Neonatal Infant Pain Scale (NIPS) was used to confirm the painful nature of the stimuli. NIPS assessment and SC measurement (Med-Storm Pain Monitor™) were simultaneously performed by two independent observers before, during and after blood sampling. Results: Sixty-eight heel prick procedures (46 for glycaemia and 22 for blood gas analysis) were applied to 16 infants. Both NIPS scores and SC peaks/s index were significantly higher during blood sampling than before or thereafter (Wilcoxon Signed Ranks, p < 0.001). There was no significant difference in NIPS score and SC peaks/s between the different heel prick procedures. Significantly higher SC area under low peaks index (Mann–Whitney, p = 0.001) and lower SC average rise time index (Mann–Whitney, p = 0.037) were registered when blood was drawn for blood gas analysis than for glycaemia, related to a sustained acute nociceptive response to a more prolonged stimulus. Conclusion: Using the conjunction of available SC indices, SC seems able to differentiate the nociceptive response to acute pain of different durations.

The adjusted effect of maternal body mass index, energy and macronutrient intakes during pregnancy, and gestational weight gain on body composition of full-term neonates.

OBJECTIVE To evaluate the effect of prepregnancy body mass index (BMI), energy and macronutrient intakes during pregnancy, and gestational weight gain (GWG) on the body composition of full-term appropriate-for-gestational age neonates. STUDY DESIGN This is a cross-sectional study of a systematically recruited convenience sample of mother-infant pairs. Food intake during pregnancy was assessed by food frequency questionnaire and its nutritional value by the Food Processor Plus (ESHA Research Inc, Salem, OR). Neonatal body composition was assessed both by anthropometry and air displacement plethysmography. Explanatory models for neonatal body composition were tested by multiple linear regression analysis. RESULTS A total of 100 mother-infant pairs were included. Prepregnancy overweight was positively associated with offspring weight, weight/length, BMI, and fat-free mass in the whole sample; in males, it was also positively associated with midarm circumference, ponderal index, and fat mass. Higher energy intake from carbohydrate was positively associated with midarm circumference and weight/length in the whole sample. Higher GWG was positively associated with weight, length, and midarm circumference in females. CONCLUSION Positive adjusted associations were found between both prepregnancy BMI and energy intake from carbohydrate and offspring body size in the whole sample. Positive adjusted associations were also found between prepregnancy overweight and adiposity in males, and between GWG and body size in females.

Nutritional risk assessment and cultural validation of the modified NUTRIC score in critically ill patients—A multicenter prospective cohort study

Purpose: Characterize the nutritional risk of critically ill patients with the modified NUTrition Risk in the Critically ill (NUTRIC) score. Materials: National, multicenter, prospective, observational study conducted in 15 polyvalent Portuguese intensive care unit (ICU), during 6 months. Adult patients were eligible. Those transferred from another ICU or readmitted, brain dead at admission, and with length of ICU stay (LOS) of 72 hours or less were excluded. NUTRIC score was calculated at admission; scores ≥5 represent a high nutritional risk. Main outcome was mortality from all causes at 28 days after admission to the ICU; LOS and days without mechanical ventilation (days free of MV) were secondary outcomes. Results: From 2061 admissions, 1143 patients were considered, mostly males (n = 744, 64.7%) with median (P25‐P75) age of 64 (51‐75). Patients at high nutritional risk were 555 (48.6%). High NUTRIC score was associated with longer LOS (P < .001), less days free of MV (P = .002) and higher 28‐day mortality (P < .001). The area under the curve of NUTRIC score ≥5 for predicting 28‐day mortality was 0.658 (95% CI, 0.620‐0.696). NUTRIC score ≥5 had a positive predictive value 32.7% and a negative predictive value 88.8% for 28‐day mortality. Conclusions: Almost half of the patients in Portuguese ICUs are at high nutritional risk. NUTRIC score was strongly associated with main clinical outcomes.

Reducing Discomfort While Measuring Crown-Heel Length in Neonates

AIM To assess the degree of discomfort caused by length measurement in neonates, performed with one or both lower limbs extended, on the first and second day after birth, with either one or both lower limbs extended. METHODS Healthy full-term neonates were systematically sampled during the months of February and March 2004. Crown-heel length was measured, using a 1-mm precision neonatometer, at approximately 8 h and 32 h after birth, with one and both lower limbs extended. The Neonatal Facial Coding System was used to assess discomfort during measurements. Data were analysed by parametric and non-parametric tests as appropriate. RESULTS Whatever the measurement technique, discomfort scores are significantly higher during the length measurement than at baseline. Whenever length measurements are performed, discomfort scores are significantly higher when extending both lower limbs rather than one lower limb (p < 0.006). The measured length is greater with one lower limb extended; however, the difference decreases over time, being 0.19 cm (95% CI 0.1-0.3; p < 0.001) at approximately 32 h of age. No significant differences in length were found between measurements at approximately 8 or 32 h, regardless of the technique used. The best correlation between length measurements with one or both lower limbs extended was observed at approximately 32 h after birth (r = 0.98). CONCLUSION Measuring crown-heel length is a distressful procedure for the neonate. Measurements with one lower limb extended result in less discomfort than when both lower limbs are extended, without decreasing the accuracy.

Is Intrauterine Growth Appropriate to Monitor Postnatal Growth of Preterm Neonates

When using the useful 2013 Fenton Chart, data should be interpreted with caution taking into account two aspects: the physiologic loss of body water after birth for the weight curves, and the questionable accuracy of the birth length curves considering the heterogeneity and reliability of the methods used in the original measurements.

Osmolality of solutions, emulsions and drugs that may have a high osmolality: aspects of their use in neonatal care

Objective: Administration of some hypertonic substances to neonates has been associated with a variety of adverse effects. This study was conducted to determine the osmolality of intravenous drugs and solutions used in neonates receiving intensive care. Methods: Osmolality was measured by freezing point depression. Vasoactive drugs, diuretics, anticonvulsants, antimicrobials, and glucose and electrolyte solutions were some of the substances analyzed. Results: The osmolalities of 90 substances were measured; the respective intra-assay and interassay coefficients of variation were always less than 5%. A few drugs were found to be extremely hypertonic (> 8000 mOsm/kg), and most of them contain propylene glycol as vehicle (e.g. digoxin, phenytoin, diazepam and phenobarbital). Other drugs, at the same concentration, evidenced a significant discrepancy of osmolality depending on the trademark. Conclusions: The finding of some extremely hypertonic drugs highlights the need for further investigation in order to study their potential adverse effects in neonates, as well as to evaluate any advantage in diluting, infusing slowly or even avoiding such substances. Given the fact that there exists a discrepancy in osmolalities in some drugs at the same concentration depending on the trademark, the more isotonic solutions should be the preferred choice for intravenous administration.

Effect of indoor air quality of day care centers in children with different predisposition for asthma

Scarce information is available about the relationships between indoor air quality (IAQ) at day care centers (DCC), the estimated predisposition for asthma, and the actual wheezing susceptibility.

Upper Arm Anthropometry Is Not a Valid Predictor of Regional Body Composition in Preterm Infants

Background: Upper arm anthropometry has been used in the nutritional assessment of small infants, but it has not yet been validated as a predictor of regional body composition in this population. Objective: Validation of measured and derived upper arm anthropometry as a predictor of arm fat and fat-free compartments in preterm infants. Methods: Upper arm anthropometry, including the upper arm cross-sectional areas, was compared individually or in combination with other anthropometric measurements, with the cross-sectional arm areas measured by magnetic resonance imaging, in a cohort of consecutive preterm appropriate-for-gestational-age neonates, just before discharge. Results: Thirty infants born with (mean ± SD) a gestational age of 30.7 ± 1.9 weeks and birth weight of 1,380 ± 325 g, were assessed at 35.4 ± 1.1 weeks of corrected gestational age, weighing 1,785 ± 93 g. None of the anthropometric measurements are reliable predictors (r2 < 0.56) of the measurements obtained by magnetic resonance imaging, individually or in combination with other anthropometric measurements. Conclusion: Both measured anthropometry and derived upper arm anthropometry are inaccurate predictors of regional body composition in preterm appropriate-for-gestational-age infants.