M. De Curtis

Enteral nutrient supply for preterm infants: commentary from the European Society of Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition.

The number of surviving children born prematurely has increased substantially during the last 2 decades. The major goal of enteral nutrient supply to these infants is to achieve growth similar to foetal growth coupled with satisfactory functional development. The accumulation of knowledge since the previous guideline on nutrition of preterm infants from the Committee on Nutrition of the European Society of Paediatric Gastroenterology and Nutrition in 1987 has made a new guideline necessary. Thus, an ad hoc expert panel was convened by the Committee on Nutrition of the European Society of Paediatric Gastroenterology, Hepatology, and Nutrition in 2007 to make appropriate recommendations. The present guideline, of which the major recommendations are summarised here (for the full report, see http://links.lww.com/A1480), is consistent with, but not identical to, recent guidelines from the Life Sciences Research Office of the American Society for Nutritional Sciences published in 2002 and recommendations from the handbook Nutrition of the Preterm Infant. Scientific Basis and Practical Guidelines, 2nd ed, edited by Tsang et al, and published in 2005. The preferred food for premature infants is fortified human milk from the infants own mother, or, alternatively, formula designed for premature infants. This guideline aims to provide proposed advisable ranges for nutrient intakes for stable-growing preterm infants up to a weight of approximately 1800 g, because most data are available for these infants. These recommendations are based on a considered review of available scientific reports on the subject, and on expert consensus for which the available scientific data are considered inadequate.

Reference values of body composition obtained by dual energy X-ray absorptiometry in preterm and term neonates

BACKGROUND As previously reported, dual-energy x-ray absorptiometry provides reliable and accurate values for bone mineralization in piglets and infants, but overestimates fat content in small infants. The purpose of the current study was to determine an appropriate equation of correction for fat mass measurement and to establish reference values of body composition of preterm and term neonates. METHODS Fat mass and chemical whole-body fat content were evaluated by dual-energy x-ray absorptiometry in eight piglets with a body weight between 1408 and 5151 g. The results were combined with previous data obtained in 13 piglets, and two correction equations were determined according to fat mass content. Close to birth, 106 healthy appropriate-for-gestational-age preterm and term infants were scanned by dual-energy x-ray absorptiometry to determine bone mineral content, bone area, and fat mass. Fat mass content determined by dual-energy x-ray absorptiometry was corrected using the equations obtained in piglets after which lean body mass was recalculated. RESULTS Multivariate analysis showed that dual-energy x-ray absorptiometry body weight was the best predictor of bone mineral content (r2 = 0.94), bone area (r2 = 0.95), lean body mass (r2 = 0.98), and fat mass (r2 = 0.84). Gender was an additional significant independent variable for fat mass and lean body mass. Body weight related curves of percentiles for bone mineral content, bone area, fat mass, and lean body mass, were constructed. In vivo dual-energy x-ray absorptiometry values of fat mass and calcium content estimated from bone mineral content were in accordance with previously reported whole-body carcass reference values in preterm and term neonates. CONCLUSION Normative data of dual-energy x-ray absorptiometry body composition for healthy preterm and term infants are provided and can therefore be used in research and in clinical practice.

Extrauterine growth restriction in very-low-birthweight infants

Postnatal growth failure of very‐low‐birthweight (VLBW) infants may result from a complex interaction of genetic and environmental factors, including inadequate nutrition, morbidities affecting nutrient requirements, endocrine abnormalities and treatments. Among VLBW infants, those small for gestational age (SGA) at birth and those with postnatal growth restriction at the time of discharge are at higher risk of later growth failure and long‐term consequences. Nutritional intervention with an “aggressive nutrition” during the first weeks of life may be able to minimize the interruption of nutrients that occurs at birth, and reduce as much as possible the incidence of growth restriction at the time of discharge and later. Even though aggressive parenteral and enteral nutrition appear to be effective and safe in VLBW infants, further evaluations of their long‐term effect on growth and health consequences are needed. Several studies evaluating the effect of enriched nutrient formulas after hospital discharge on growth and neurodevelopment have produced conflicting results, whereas the potential deleterious long‐term effects of prolonged use of high protein and/or of later catch‐up growth have been questioned. In contrast, recent data seem to indicate that the use of human milk after hospital discharge could be the most beneficial diet for subsequent health and development.

Effect of fortification on the osmolality of human milk

AIM To evaluate the effect of fortification on the osmolality of human milk. METHODS The osmolality of 47 samples of human milk was determined at baseline, just after, and 24 hours after supplementation with five different human milk fortifiers (HMF) at 4°C. RESULTS Ten minutes after HMF supplementation the osmolality of human milk was significantly higher than the sum of the respective values of HMF dissolved in water and human milk, measured separately at baseline (p<0.0001), with the exception of the HMF containing only proteins. After 24 hours a further increase in osmolality was observed. Linear regression analysis showed that total dextrin content (r=0.84) was the main determinant of the increase. CONCLUSIONS Human milk and HMF interact to induce a rapid increase in osmolality higher than would be expected from composition alone. This rise could be explained by the amylase activity of human milk, inducing hydrolysis of the dextrin content of HMF, leading to small osmotically active molecules of oligosaccharides. The high osmolality of fortified human milk should be considered in the nutritional management of preterm infants.

Neonatal anthropometric charts: what they are, what they are not.

Over 40 years have elapsed since Lubchenco et al 1 proposed an anthropometric classification of neonates based on the so-called intrauterine growth charts—that is, birth weight-for-gestational age charts. The use of charts, such as those given by Lubchenco et al ,1 based on the distribution of measurements taken on neonates with different gestational age, should be restricted to the auxological assessment of babies at birth. These charts, now called neonatal anthropometric charts, must not be confused with the intrauterine growth charts, which are a tool for monitoring fetal growth, based on ultrasound measurements of anthropometric traits during pregnancy: preterm births are abnormal events and preterm neonates cannot be equated to fetuses of the same gestational age who will be born at term.2 When fetal growth studies are longitudinal, both distance and velocity intrauterine growth charts may be traced.3,4 Strictly speaking, only charts derived from longitudinal studies should be called growth charts, growth being a process extended over time. The terms SGA and intrauterine growth restriction (IUGR) are often used as synonyms, although they reflect two different concepts. SGA refers to a statistical definition, based on an auxological cross-sectional evaluation (prenatal or neonatal), and denotes a fetus or a neonate whose anthropometric variables (usually weight) are lower than a given threshold value computed on a set of infants having the same gestational age. SGA includes infants who have not achieved their own growth potential, because of maternal, uterine, placental and fetal factors,5,6 as well as small but otherwise healthy infants. IUGR refers to a clinical and functional condition and denotes fetuses unable to achieve their own growth potential: a fetus with IUGR would have been larger, without adverse environmental or genetic factors affecting growth. Such a condition can be assessed by ultrasonography during pregnancy by …

Fatal congenital myopathy and gastrointestinal pseudo-obstruction due to POLG1 mutations

Mutations in the gene coding for the catalytic subunit of the mitochondrial DNA (mtDNA) polymerase γ ( POLG1 ) are associated with a range of clinical syndromes characterized by secondary mtDNA defects, including mtDNA depletion and multiple mtDNA deletions.1 The phenotypic spectrum of POLG1 -associated disease ranges from fatal childhood encephalopathy with intractable epilepsy and liver failure (Alpers-Huttenlocher syndrome)2 to late-onset clinical disease affecting a single organ (for a review, see reference 3). We describe a fatal skeletal and visceral myopathy in the neonatal period associated with recessive POLG1 mutations. ### Case report. A newborn boy of healthy nonconsanguineous parents was delivered at 37 weeks’ gestation by cesarean section. His mother (primipara, 32 years old) had been admitted to our hospital 2 weeks previously because of reduced fetal intrauterine movements and polyhydramnios. The child’s birthweight was 2,330 g (<10th percentile), length 47 cm, and head circumference 33.2 cm (25th percentile). He had low-set ears and bilateral clubfoot. Apgar scores were 2, 6, and 7 at 1, 5, and 10 minutes. The child presented with severe hypotonia and generalized muscle weakness, requiring ventilatory assistance and total parenteral nutrition. Weaning failed because of inadequate pulmonary ventilation and respiratory acidosis. Hearing loss was detected by auditory evoked potentials, while cranial MRI showed mildly enlarged ventricles and liquor spaces. Two days …

Diarrhoea in jaundiced neonates treated with phototherapy: role of intestinal secretion.

Thirty jaundiced neonates with diarrhoea who were being treated with phototherapy and 30 matched control infants were studied to try and find out the cause of the diarrhoea. Faecal osmolality and electrolyte concentrations were measured, which gave clear evidence that the diarrhoea arose from intestinal secretion. Rectal water and electrolyte absorption in 10 jaundiced infants receiving phototherapy, in 10 jaundiced infants not receiving phototherapy, and in 10 healthy controls was measured with a rectal dialysis bag. A further group of eight jaundiced infants was also studied both during and after phototherapy to document the reversal of ion transport changes. Absorption of water, sodium chloride, and potassium was significantly impaired in the patients receiving phototherapy compared with each of the control groups. Such impairment was transient, as it was not apparent when the jaundice faded and phototherapy was stopped. These data show that the colon plays a part in the pathogenesis of secretory diarrhoea and that both hyperbilirubinaemia and phototherapy are necessary for such an effect to develop.

Effect of taurine supplementation on fat and energy absorption in cystic fibrosis.

In 10 children with cystic fibrosis and persisting steatorrhoea, supplementation with taurine (30-40 mg/kg/day) was given for two months as an adjunct to the usual pancreatic enzyme treatment. A three day fat and energy balance was performed in patients with cystic fibrosis, before and after the supplementation, and in seven healthy controls who did not receive taurine. Faecal fat was measured by a gravimetric method and stool energy was determined using a bomb calorimeter. Patients with cystic fibrosis, before and after taurine, and healthy controls received the same fat and energy intake (calculated by a dietitian). In patients with cystic fibrosis taurine did not produce any improvement of steatorrhoea (mean (SD) faecal fat 8.7 (3.3) v 11.2 (7.0) g/day, respectively before and after the supplementation), of faecal energy loss (0.978 (0.468) v 1.133 (0.539) MJ/day), of faecal fat expressed as percent of fat intake (13.4 (5.6) v 15.1 (9.8)%), and of faecal energy expressed as percent of energy intake (9.9 (3.6) v 11.2 (5.7)%). Healthy controls had significant lower fat (3.5 (2.3) g/day) and energy 0.576 (0.355) MJ/day faecal losses. In conclusion, taurine failed to decrease significantly fat and energy losses. Our study does not support the use of taurine supplementation in the nutritional management of cystic fibrosis.

Accuracy of transcranial ultrasound in the detection of mild white matter lesions in newborns

Cranial Ultrasound (cUS) may not be sensitive enough to detect subtle white matter (WM) injuries. Our study compared serial cUS with MRI at term equivalent age (TEA) to determine if it is possible to identify an ultrasound representation of subtle diffuse WM injuries such as punctate lesions (PWMLs) and diffuse excessive high signal intensity (DEHSI). Fifty-six very preterm infants were scanned sequentially from birth to TEA, an MRI was performed at TEA. Each echodensity found on cUS was classified as absent, transient (≤7 days), or prolonged (>7 days). A transient periventricular echodensity was detected in seven infants (12.5%), and a prolonged echodensity in 15 (26.8%). MRI examinations were performed in all 56 infants. No altered signal intensity was found in 18 infants (32.1%). DEHSI was detected in 14 infants (25%), and PWMLs were detected in eight babies (14.3%). Both abnormalities were found in 16 infants (28.6%). The positive predictive values of the prolonged echodensity for DEHSI and PWMLs were 86.7% and 46.7% respectively. However, a significant statistical correspondence (p=0.002, Odds Ratio 11.9) was found comparing DEHSI with cUS abnormal echodensities. Serial cUS during the neonatal period in preterm infants is essential and cannot be replaced with MRI at TEA. MRI seems to be more reliable in detecting mild or moderate WM abnormalities. However, serial cUS performed by an experienced neonatologist can provide valuable information on early WM changes such as prolonged echodensities that could potentially lead to a diffuse injury.

Energy and nitrogen balances in very low birthweight infants.

Energy and nitrogen balances were performed in 12 very low birthweight infants fed on either human milk or on a preterm formula. Energy and nitrogen retention were significantly higher in those given the formula feed (p less than 0.05). Highly significant correlations were found between nitrogen intake and nitrogen retention and between energy retention and nitrogen retention (p less than 0.001). Multiple regression analysis failed to show any effect of energy retention on the correlation between nitrogen intake and nitrogen retention in babies fed on human milk. Protein deficiency seems to be the most likely explanation of poor growth in infants fed on human milk.