Micaela Serelha

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.

Osmolality of elemental and semi-elemental formulas supplemented with nonprotein energy supplements.

BACKGROUND Elemental and semi-elemental formulas are used to feed infants with short bowel syndrome, who may not be able to tolerate feeds of more than 310 mOsm kg(-1). The present study aimed to measure the osmolality of elemental and semi-elemental formulas at different concentrations, with and without the addition of nonprotein energy supplements. METHODS The osmolality of one elemental and three semi-elemental formulas was measured by the freezing point depression method at concentrations of 10, 12, 14 and 16 g per 100 mL, with and without 10% or 20% of additional calories, in the form of glucose polymers and medium chain triglycerides. Inter-analysis and intra-analysis coefficients of variation of the measurements were less than 3.9%. RESULTS The mean osmolalities of formulas reconstituted up to 12 g per 100 mL did not exceed 305.3 mOsm kg(-1), even with added energy supplements. The mean osmolalities of formulas at 14 and 16 g per 100 mL, with or without added energy supplements varied between 205.8 and 421.6 mOsm kg(-1). CONCLUSIONS A comprehensive list of elemental and semi-elemental formulas at different concentrations, enriched or not with calories, is made available. This will enable professionals to customize feeds with the optimum composition, without exceeding the osmolality suggested for infants with short bowel syndrome.

Osmolality of preterm formulas supplemented with nonprotein energy supplements.

Background:Addition of energy supplements to preterm formulas is an optional strategy to increase the energy intake in infants requiring fluid restriction, in conditions like bronchopulmonary dysplasia. This strategy may lead to an undesirable increase in osmolality of feeds, the maximum recommended safe limit being 400 mOsm/kg. The aim of the study was to measure the changes in osmolality of several commercialized preterm formulas after addition of glucose polymers and medium-chain triglycerides.Methods:Osmolality was measured by the freezing point depression method. Six powdered formulas with concentrations of 14 g/100 ml and 16 g/100 ml, and five ready-to-feed liquid formulas were analyzed. All formulas, were supplemented with 10% (low supplementation) or 20% (high supplementation) of additional calories, respectively, in the form of glucose polymers and medium chain triglycerides, maintaining a 1:1 glucose:lipid calorie ratio. Inter-analysis and intra-analysis coefficients of variation of the measurements were always < 3.9%.Results:The mean osmolality (mOsm/kg) of the non-supplemented formulas varied between 268.5 and 315.3 mOsm/kg, increasing by 3–5% in low supplemented formulas, and by 6–10% in high supplemented formulas. None of the formulas analyzed exceeded 352.8 mOsm/kg.Conclusion:The supplementation of preterm formulas with nonprotein energy supplements with up to 20% additional calories did not exceed the maximum recommended osmolality for neonatal feedings.

Does the Intake of LC-PUFAS During Pregnancy Affect the Body Composition of Term Neonates? Preliminary Results

Background: The effect of the intake of polynsaturated long chain fatty acids (LCPUFAs) during pregnancy on fetal body composition has been assessed by studies using mostly neonatal anthropometry. Their results have been inconsistent, probably because neonatal anthropometry has several validity limitations. Air displacement plethismography (ADP) is a recently validated non-invasive method for assessing body composition in neonates.Objective: To determine the effect of the intake of LCPUFAs during pregnancy on the body composition of term neonates, measured by ADP.Methods: Cross-sectional study of a convenience sample of healthy full-term neonates and their mothers. The diet during pregnancy was assessed using a validated semi-quantitative food frequency questionnaire; Food Processor Plus® was used to convert food intake into nutritional values. Body composition was estimated by anthropometry and measured by ADP using Pea Pod™ Life Measurements Inc (fat mass - FM, fat-free mass and %FM) within the first 72h after birth. Univariate and multivariate analysis (linear regression model) were performed.Results: 54 mother-neonate pairs were included. Multivariate analysis adjusted to the maternal body mass index shows positive association between LCPUFAs intake and neonatal mid-arm circumference (= 0,610, p = 0,019) and negative association between n-6:n-3 ratio intake and neonatal %FM (= -2,744, p=0,066).Conclusion: To the best of our knowledge, this is the first study on this subject using ADP and showing a negative association between LCPUFAs n-6:n-3 ratio intake in pregnancy and neonatal %FM. This preliminary finding requires confirmation increasing the study power with a greater sample and performing interventional studies.

265 Elective Nasal CPAP Vs Modern Conventional Ventilation in Preterm Newborn Babies

Background: In 2001, after reopening of the hospital maternity, it was possible to start elective nasal CPAP (EnCPAP) in preterm babies needing ventilatory support. At that time, modern conventional ventilation (MCV) − patient triggered ventilation with guarantee volume − SIPPV+GV and PSV+GV − was also started. Objective: To compare data between babies with EnCPAP and those with MCV. Kind of study: observational. Population: All preterm newborn babies born at our maternity from April 2001 thought December 2004, admitted at the NICU, without congenital abnormalities, were enrolled. Babies electively selected and exclusively ventilated with nCPAP were enrolled in the EnCPAP group; the remaining, including those selected for EnCPAP but in whom this kind of support failed, were enrolled in the MCV group. Results: During the period of the study there were 285 illegible newborn babies; 161 needed respiratory support: 86 (53,4%) MCV and 75 (46,6%) EnCPAP. During the study period the use of EnCPAP increased from 37% to 58%. Babies under EnCPAP had higher gestational age (GA) (median 32 vs. 30w, p=0.000) and birth weight (median 1660 vs. 1298g, p = 0.000). Severity scores (CRIB, NTISS and SNAP) were significantly lower in babies under EnCPAP; also they had significant higher rate of prenatal steroids (96.3% vs. 82.9% p=0.03), lower incidence of HMD (24% vs. 68,6% p=0.000), BPD (0% vs. 8.1% p=0.03), PVL (2.7% vs 11,6% p=0.065) and pneumothorax (1,3% vs. 2.3% p= 0.9). Conclusion: Despite new and more physiologic modes of CV this continues to be an invasive treatment. Nasal CPAP is a valid alternative that should be offered to those healthy preterm newborn babies with full prenatal care.

212 Osmolality of Preterm Formulas Supplemented with Glucose Polymers and Medium Chain Triglycerides

Background: Addition of energy supplements to preterm formulas is a possible strategy to increase the enteral energy intake, without exceeding the protein intake or the potential renal solute load, in infants submitted to fluid restriction, such as in bronchopulmonary dysplasia. This manipulation of standard formulas may lead to undesirable increase in osmolality of feedings, 400 mOsm/kg is the maximum recommended limit.Objective: To measure the osmolality of some commercialized preterm formulas supplemented with glucose polymers (PG) and medium chain triglycerides (MCT).Methods: Osmolality was measured by freezing point depression. Powdered formulas Aptamil Prematil® (Numico-Milupa), Enfamil Premature® (Mead-Johnson), Nenatal® (Numico-Nutricia) Nutribén Bajo Peso® (Alter) and Pre Nan® (Nestlé), at concentrations of 14g/100ml (14%) and 16g/100ml (16%), and the liquid formula Humana 0® (Humana) were analyzed. All powdered formulas at both mentioned concentrations, and the liquid formula, were supplemented with 10% (low supplementation – LS) and 20% (high supplementation – HS) of calories, respectively, as PG (Moducal®, Mead-Johnson) and MCT (MCT oil Module®, SHS) maintaining a 1:1 glucose:lipid calorie ratio. The approximate mean caloric densities (Kcal/100ml) of the preparations were 71 (14%), 78 (14% LS), 85 (14% HS), 81 (16%), 89 (16% LS) and 98 (16% HS); 75 (liquid), 83 (liquid LS) and 90 (liquid HS). The amount of macronutrients provided by each preparation and the respective potential renal solute load were registered. The Inter-analysis and intra-analysis coefficients of variation of the measurements were always <3.9%.Results: The osmolality (mOsm/Kg) of powdered formulas (mean ±SD) at 14g/100mL (273.8 ±16.5) increased 4% with LS (283.8 ±18.1) and 6% with HS (290.6 ±18.8); the osmolality of powdered formulas at 16g/100mL (312.8 ±17.7) increased 5% with LS (329.8 ±19.3) and 10% with HS (343.6 ±18.6); the osmolality of the liquid formula (331.3 ±3.5) increased 4% with LS (347.0 ±2.2) and 6 with HS (352.8 ±2.7). The potential renal solute load of all the preparations was always <24.2 mOsm/100 kcal.Conclusion: Almost all supplemented and non supplemented formulas provide the minimum energy necessary for infants submitted to fluid restriction, without associated excessive protein intake or excessive potential renal solute load. No formula analysed, including supplemented formulas, exceeded the maximum recommended osmolality for neonatal feedings.