Paula G. Radmacher

Postnatal malnutrition of extremely low birth-weight infants with catch-up growth postdischarge.

Objective: To assess nutritional intakes and subsequent growth of extremely low birth-weight (BW) infants.Study Design: Chart review of 69 extremely low BW infants stratified into two groups by BW: ≤750 g (group 1; n=27) or 751 to 1000 g (group 2; n=42). Dietary intakes, weights, and head circumferences (HC) were collected through discharge and at 1 month postdischarge. The differences between goals and intakes were calculated weekly during hospitalization. Descriptive comparisons were made between growth parameters at birth, discharge, and follow-up.Results: Total energy and protein deficits were inversely related to BW. Both groups exhibited extrauterine growth retardation while hospitalized. After discharge, the rates of weight gain and HC growth increased, leading to some growth recovery at follow-up.Conclusions: Existing feeding methods resulted in sizeable deficits in energy and protein, particularly for the smallest infants. Changing current practices to limit these deficits is essential to improving postnatal growth.

Prediction of Extrauterine Growth Retardation (EUGR) in VVLBW Infants

BACKGROUND:Long-term growth failure in very very low birth weight (VVLBW) infants is a common complication of extreme prematurity. Critical illnesses create challenges to adequate nutriture.PURPOSE:To identify predictors of extrauterine growth retardation (EUGR) in VVLBW infants and to evaluate their nutritional intake and subsequent growth.STUDY DESIGN: A 4-year retrospective chart review of 221 infants ≤1000 g birth weight and ≤29 weeks gestational age who were admitted within 24 hours of birth, were free of major congenital anomalies and survived at least 7 days. Daily intakes and anthropomorphic data were collected and analyzed. Significant events during hospitalization were documented.RESULTS: Mean energy and protein intakes during hospitalization did not reach recommendations of 120 kcal/kg/d and 3.0 g/kg/day. In utero growth rates could not be consistently reached or sustained. As expected, BW (as measured by BW percentile score) was highly predictive of EUGR (p<0.001). When the independent effect of other predictors of EUGR was considered, only days of total parenteral nutrition (p<0.001) and HC percentile at return to birth weight (p<0.001) made a significant contribution to the prediction of EUGR, once the effect of BW was taken into account.

Early amino acids and the metabolic response of ELBW infants (≤ 1000 g) in three time periods

Objective:To evaluate early amino-acid (AA) administration in extremely low birth weight (ELBW) infants over three time periods, beginning with the initiation of this strategy.Study design:This was a retrospective study of ELBW infants between 2000 and 2007. Nutritional intake and laboratory results were monitored during the first 5 days of life. Growth rates and complications were followed until discharge.Result:Infants were similar in birth weight (BW), gestational age (GA) and severity of illness. The age at initiation of AA decreased significantly over time. Age at weight nadir, return to BW and percent postnatal weight loss decreased in epoch 3. There were modest increases in blood urea nitrogen (BUN), but no significant metabolic disturbances were observed. Cholestasis was more prevalent in epoch 2.Conclusion:AA administration within the first hours of life appears to be safe and beneficial for ELBW infants. Absent signs of renal dysfunction, a modest rise in BUN is consistent with the neonates utilization of AAs for energy.

Nutritional strategies and growth in extremely low birth weight infants with bronchopulmonary dysplasia over the past 10 years.

Objective:Changes in nutritional strategies over the past decade have been shown to improve postnatal growth in extremely low birth weight (ELBW) infants. We showed 10 years ago that the majority of these ELBW infants with bronchopulmonary dysplasia (BPD) suffer postnatal growth failure. We theorized that recent changes in nutritional support strategies would positively affect growth outcomes in ELBW infants with BPD.Study Design:A retrospective study of 88 ELBW infants with BPD. Nutritional data, postnatal growth and BPD severity were compared across three cohorts: (1) weight gain ⩽14 g kg−1 per day, (2) 14.1 to 16 g kg−1 per day and (3) ⩾16 g kg−1 per day from return to birth weight through discharge. We also compared these to a historical cohort.Result:In all, 73% of current subjects grew at or above fetal rates. There was less extrauterine growth restriction (EUGR) by weight and head circumference for those ELBW infants with BPD receiving higher amounts of protein. Aggressive early TPN and receipt of caloric-dense milk seemed to be the ‘new’ nutritional strategies improving growth for current ELBW infants with BPD compared with those 10 years ago.Conclusion:Despite a diagnosis of BPD, improved nutritional strategies have enhanced postnatal growth in infants at high risk for EUGR.

Hidden Morbidity With “Successful” Early Discharge

OBJECTIVE: This study was conducted to determine if early postnatal discharge (EDC; ≤48 hours) in well newborns had an effect on the rate of hospital readmission within the first week after hospital discharge when compared to infants who remained >48 hours after birth (later discharge, LDC).STUDY DESIGN: This was a retrospective medical chart review. Charts of infants born between January 1994 and December 1998, discharged as “well newborns” and treated subsequently at a primary childrens hospital within 7 days of neonatal discharge, were reviewed. Infants were categorized by length of neonatal hospital stay, level of medical intervention (emergency department treatment or hospital admission), and final diagnosis.RESULTS: There was a significant increase in hospital readmission rate for LDC infants when compared to EDC infants. When considering jaundice alone as an admitting diagnosis, EDC infants were admitted at a higher rate than LDC infants and with higher serum bilirubin concentrations. Readmitted, jaundiced infants had been almost always breast-fed.CONCLUSION: Overall, EDC of well newborns appears to be a safe and reasonable practice. However, the risk for severe jaundice is an unresolved issue that requires a discharge strategy and early follow-up to prevent serious morbidity.

A retrospective analysis of the effect of human milk on prevention of necrotizing enterocolitis and postnatal growth

Objective:The objective of this study is to determine whether the use of donor human milk (DHM) in very low birth weight (VLBW, ⩽1500 g) neonates in a large neonatal intensive care unit (NICU) affected the rate of necrotizing enterocolitis (NEC) or impacted growth.Study Design:This was a retrospective chart review of 550 VLBW neonates following the introduction of DHM as the preferred diet if maternal breast milk (MBM) was not available. Demographics, growth parameters, incidence of NEC or death and days of DHM or MBM were extracted from charts.Result:Compared with infants who received human milk (HM) on fewer than 50% of hospital days, neonates who received HM on ⩾50% of hospital days had equivalent growth outcomes but lower rates of NEC (NEC 3.4 vs 13.5%, P<0.001) and mortality (1.0 vs 4.2%, P=0.017). Growth and NEC rates were inversely correlated with the duration of exposure to HM.Conclusion:HM should always be the diet of choice in preterm infants. DHM is a safe alternative, if MBM is not available. Although the use of HM is associated with lower rates of NEC, growth rates were significantly lower in infants with significant HM intake. The decline in growth rates following the introduction of DHM should draw attention to optimize fortification of all HM feedings.

Fortification of Human Milk in Very Low Birth Weight Infants (VLBW <1500 g Birth Weight)

The American Academy of Pediatrics supports the feeding of human milk for all infants. Very-low-birth-weight and extremely low-birth-weight infants especially can benefit from the immune and neurodevelopmental effects of human milk. However, human milk alone is nutritionally inadequate for the rapid growth of the very-low-birth-weight infant during a critical window for brain development and requires fortification to meet current recommendations. There are a variety of products, devices, and strategies that can be used to fine tune nutritional support of these very vulnerable infants.

Individualizing fortification of human milk using real time human milk analysis.

OBJECTIVE To use real-time human milk macronutrient analysis to calculate final composition following fortification. STUDY DESIGN Preterm HM (PHM) and pooled donor human milks (DHM) were analyzed by mid-infrared spectroscopy for protein, fat and lactose. Energy content was calculated from macronutrient results. Three lactation stages were constructed. DHM was compared to PHM. Four milk sample profiles were selected to demonstrate individualized fortification results. RESULTS Lactose was similar in PHM and DHM. Protein in PHM showed the expected decline as lactation progressed. DHM protein was significantly lower vs. PHM. Fat was highly variable and lowest in DHM. Using standard fortification protocols, not all fortified milks met targets for protein and energy. Individualized fortification resulted in milks closer to target recommendations. CONCLUSIONS Real-time analysis of HM provides assessment of the macronutrient content of the milk and can guide fortification. Individualized protocols, based on actual milk macronutrient profiles, may need to be considered to avoid unexpected nutrient content.

Stability of lactoferrin in stored human milk

Objective:Lactoferrin from human milk (HM) provides antimicrobial and anti-inflammatory action in the neonatal intestine. HM-fed, critically ill neonates often receive previously frozen milk. Freezing is known to have deleterious effects on proteins. The aim of this study was to determine the effect of low temperature storage of HM on the concentration of lactoferrin.Study design:HM samples were collected and stored for different periods of time and at different temperatures per Centers for Disease Control and Prevention recommendations. Lactoferrin concentrations following freezing were compared with that in fresh HM.Result:Lactoferrin concentrations in refrigerated HM samples were stable for 5 days. After 3 months at −18 to −20 C, the average decrease was 37%. Following storage for 6 months at −20 °C, lactoferrin decreased to 46%.Conclusion:Five-day refrigeration of HM does not appreciably decrease lactoferrin levels. Freezing HM for 3 months or more significantly lowers lactoferrin levels. There may be a role for occasionally providing fresh HM to critically ill neonates.

Creamatocrit analysis of human milk overestimates fat and energy content when compared to a human milk analyzer using mid-infrared spectroscopy.

Background and Objective: Human milk (HM) is the preferred feeding for human infants but may be inadequate to support the rapid growth of the very-low-birth-weight infant. The creamatocrit (CMCT) has been widely used to guide health care professionals as they analyze HM fortification; however, the CMCT method is based on an equation using assumptions for protein and carbohydrate with fat as the only measured variable. The aim of the present study was to test the hypothesis that a human milk analyzer (HMA) would provide more accurate data for fat and energy content than analysis by CMCT. Methods: Fifty-one well-mixed samples of previously frozen expressed HM were obtained after thawing. Previously assayed “control” milk samples were thawed and also run with unknowns. All milk samples were prewarmed at 40°C and then analyzed by both CMCT and HMA. CMCT fat results were substituted in the CMCT equation to reach a value for energy (kcal/oz). Fat results from HMA were entered into a computer model to reach a value for energy (kcal/oz). Fat and energy results were compared by paired t test with statistical significance set at P < 0.05. An additional 10 samples were analyzed locally by both methods and then sent to a certified laboratory for quantitative analysis. Results for fat and energy were analyzed by 1-way analysis of variance with statistical significance set at P < 0.05. Results: Mean fat content by CMCT (5.8 ± 1.9 g/dL) was significantly higher than by HMA (3.2 ± 1.1 g/dL, P < 0.001). Mean energy by CMCT (21.8 ± 3.4 kcal/oz) was also significantly higher than by HMA (17.1 ± 2.9, P < 0.001). Comparison of biochemical analysis with HMA of the subset of milk samples showed no statistical difference for fat and energy, whereas CMCT was significantly higher than for both fat (P < 0.001) and energy (P = 0.002). Conclusions: The CMCT method appears to overestimate fat and energy content of HM samples when compared with HMA and biochemical methods.