Robert J Tinnion

Preterm birth and subsequent insulin sensitivity: a systematic review

Objective The incidence of preterm birth is increasing worldwide. Evidence suggests that in later life these children are at increased risk of ‘metabolic syndrome’, which is itself associated with reduced insulin sensitivity (IS). We carried out a systematic review to examine whether preterm birth is associated with later changes in IS and whether a difference exists between those born small-for-gestational age (SGA) and appropriate-for-gestational age (AGA). Methods We used the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidance to structure our review with a priori data extraction criteria to answer the questions posed and then carried out our literature search. Only papers which included preterm infants in their study population and specifically assessed IS were included. Findings are reported by age group to enable change over the life course to be examined, even though the studies were mostly cross-sectional, observation studies. Results We identified and reviewed 26 suitable publications representing 20 separate cohorts, of which 16 had a term control group. The heterogeneity of the methods used to measure IS precluded meta-analysis. In infancy and early childhood there is a measurable association between IS and preterm birth. In later childhood and adulthood the strength of this association reduces, and current body composition becomes the variable most strongly associated with IS. Conclusions There is an association between preterm birth and IS throughout the life course, but the data are conflicting and associations are likely to be affected by the heterogeneity of each study population and multiple confounding factors that may change over time. While the optimal nutritional strategy for preterm infants remains to be determined, standard public health guidance to avoid obesogenic lifestyle factors remains equally important to individuals born preterm.

How to use… alkaline phosphatase in neonatology

Alkaline phosphatase (ALP) is regularly measured in clinical practice. Changes in serum levels are observed in a number of clinical conditions. In neonatology, it has been proposed as a useful marker for both a diagnosis and an indication of the severity of metabolic bone disease (MBD) in infants born preterm. Nutritional practices, aimed at reducing the occurrence or severity of MBD, have led to ALP being proposed as a stand-alone means of monitoring treatment. The current evidence does not support this use: ALP only achieves usefulness in a diagnostic and monitoring capacity when combined with other serum and imaging techniques.

RSV: Immunoprophylaxis and non‐invasive respiratory support in ex‐preterms: A northern UK perspective

Recent guidance has suggested that immunoprophylaxis with monoclonal antibody against respiratory syncytial virus (RSV) should be extended to ex‐preterm infants who are moderate‐to‐late‐preterm and discharged home during the RSV season. Noninvasive respiratory support (NIV) for infants with bronchiolitis is becoming widespread with little supporting evidence for efficacy over nonpressure support methods. We used multicentre prospective audit and service evaluation to evaluate whether extension of current practice in line with the guidance would provide a clinical or cost benefit, and whether NIV provides any benefits in the ex‐preterm population. The prevalence of bronchiolitic illness requiring admission in our population was similar to other studies (2.5%). We found that the majority of ex‐preterm infants with RSV positive bronchiolitis who required NIV did not meet the extended criteria for immunisation. Our data suggest that extending RSV prophylaxis as recommended would be unlikely to reduce numbers of infants requiring respiratory support for RSV. NIV use has been widely adopted (9% of ‘bronchiolitic’ admissions) in our region but the data do not support it as a useful adjunct for ex‐preterms with RSV positive illness requiring respiratory support: it does not appear to reduce the need for subsequent formal ventilation. Our study does not support a case for change to more widespread, protocol driven immunisation for RSV. Further research is needed in a randomised, controlled setting to examine the use of NIV in bronchiolitis in a wider context. Pediatr Pulmonol. 2015; 50:1119–1127.

Catch up Growth and the Developmental Origins of Health and Disease (DOHaD) in Preterm Infants

Preterm infants are vulnerable to the effects of malnutrition in both the pre- and post-discharge period. On-going illness and immaturity result in a delay in the establishment of adequate nutrition. During this period, cumulative nutrient deficits are accrued and growth is poor. The majority of preterm infants are discharged with a weight lower than their birth centile, indicative of poor growth. Nutrition has the potential to promote catch-up growth, although growth acceleration in some situations is associated with increased risk of metabolic problems in the longer term. Controlled trial data show that early nutrient intakes may ‘programme’ a range of long term metabolic outcomes. The Developmental Origins of Health and Disease (DOHaD) theory amalgamates many areas of scientific study and encompasses a wide range of diverse disciplines from epidemiology to molecular biology. The mechanisms linking early growth to later outcomes include permanent structural changes, accelerated cellular ageing and epigenetic mechanisms. There are data to link faster early growth with decreased insulin sensitivity in children born preterm, but many other long-term effects do not demonstrate consistent associations with early growth. Despite such potential metabolic concerns, the current data suggest that promoting improved nutrient intake and catch up growth in the pre- and post-discharge period is likely to result in better neurocognitive outcomes.

Question 2: Will continuous positive airway pressure reduce the need for ventilation in bronchiolitis?

You are asked to see a 2-month-old boy who has been ill for 3 days. He has respiratory syncytial virus positive bronchiolitis and is needing 1.5 L/min oxygen by low flow. His capillary blood gas has pH 7.26 pCO2 9.9 kPa pO2 4.5 kPa and base excess −5.0. His respiratory rate is 60 and increasing. The family has been told he may need moving to 40 miles to the regional paediatric intensive care unit (PICU). They are worried and angry, not least because his sister is delivering a baby upstairs. You wonder whether starting continuous positive airway pressure (CPAP) will reduce the need for ventilation and help keep them together. In an infant less than 2 years old with bronchiolitis will early use of CPAP reduce the need for intubation and ventilation? Medline, CINAHL and EMbase …

1437 Markers of the Metabolic Syndrome and Physical Activity in Teenage Children Born Preterm

Background and Aims The worldwide increase in the Metabolic Syndrome is associated with adverse health outcomes and significant healthcare costs. Early life exposures are key factors in determining later health. Children born preterm appear to be at higher risks of developing insulin resistance. We aimed to determine the prevalence of novel metabolic biomarkers in a cohort of teenage children who were born preterm (< =34 weeks gestation) and correlate these with physical activity. Methods We studied 24 children using standard techniques including auxology, body composition (BODPOD™), insulin resistance (fasting and post-glucose load) and daily activity (Actigraph™ and Actilife™ software). We measured 31-P and 1-H magnetic resonance spectroscopy (MRS) and assessed intra-hepatic lipid (IHL) content and phospho-creatine recovery after standardised exercise within the MR scanner. Results IHL was associated with increases in body mass and fat mass index (% body fat/height2). There was a weak association between glucose levels and muscle recovery time with increased IHL. Recovery from exercise was correlated with % time spent in daily moderate-to-vigorous physical activity (MVPA) and sedentary activity. Only 5 children achieved an activity time within 10% of the recommended 60 minutes or more of MVPA per day (mean:39 minutes). Conclusions Children born preterm have evidence of adverse metabolic outcomes in later life. IHL deposition is related to overall fatness, and may be significant in adverse metabolic processes. Measured physical activity correlates with the ability of muscle to recover from a defined exercise. Improving MVPA may result in health benefits.

Rhizomelic chondrodysplasia punctata: a classic ‘spot’ diagnosis

Figures 1 and 2 are radiographs from a neonate admitted to our neonatal intensive care unit. He was delivered by ventouse, at term, requiring no resuscitation. Detailed antenatal ultrasound had shown disproportionately shortened humeri with indistinct metaphyses suggesting a significant skeletal dysplasia. Examination confirmed proximally shortened limbs, hip and knee contractures, bilateral lens opacities and dysmorphic facial features …