Thibault Senterre

Optimizing early nutritional support based on recent recommendations in VLBW infants and postnatal growth restriction

Objective: The aim of this study was to evaluate postnatal growth up to discharge in very low birth weight infants after optimizing nutritional support based on recent nutritional recommendations. Patients and Methods: A prospective, nonrandomized, consecutive, and observational study in infants weighing <1250 g. Results: One hundred two infants were included during a 2-year period (birth weight 1005 ± 157 g, gestational age 28.5 ± 1.9 weeks). First-day nutritional intake was 38 ± 6 kcal/kg/day with 2.4 ± 0.3 g/kg/day of protein. Mean intake during the first week of life was 80 ± 14 kcal/kg/day with 3.2 ± 0.5 g/kg/day of protein. On average from birth to discharge, 122 ± 10 kcal/kg/day and 3.7 ± 0.2 g/kg/day of protein were administered. Postnatal weight loss was limited to the first 3 days of life, and birth weight was regained after 7 days in average. Catch-up occurred after the second week in all groups of very low birth weight infants. Small-for-gestational age infants demonstrated an earlier and higher weight gain, allowing a rapid catch-up growth. The same proportion of infants was small-for-gestational age at birth and at discharge (20%, P = 0.74). Conclusions: This study confirmed that the first week of life is a critical period to promote growth and that early nutrition from the first day of life is essential. Postnatal weight loss may be limited and subsequent growth may be optimized with a dramatic reduction of postnatal growth restriction.

Reduction in postnatal cumulative nutritional deficit and improvement of growth in extremely preterm infants

Aim:  To evaluate the influence of gestational age (GA) on cumulative nutritional deficit and postnatal growth in extremely preterm (EPT) infants after optimizing nutritional protocol as recently recommended.

Benefits of a New Pediatric Triple-Chamber Bag for Parenteral Nutrition in Preterm Infants

Objectives: The aim of this study was to evaluate the efficacy, safety, flexibility, and ease of handling and use of the Ped3CB-A 300 mL, the first ready-to-use multichamber parenteral nutrition (PN) system, with optional lipid bag activation, specially designed for administration to preterm infants. Materials and Methods: In this prospective, open-label, multicenter, noncomparative, phase III clinical trial, preterm infants were treated with Ped3CB-A for 5 to 10 consecutive days. Results: A total of 113 preterm infants were enrolled in the study and 97 (birth weight 1382 ± 520 g; gestational age 31.2 ± 2.5 weeks; postnatal age administration 5.6 ± 6.1 days) were included in the per protocol analysis accounting for 854 perfusion days. Double-chamber bag activation was used for 32 perfusion days. Macronutrient, electrolyte, and mineral supplements were primarily administered through a Y-line or directly in the activated bag. In all, 199 additions (mainly sodium, 95%) were made to the Ped3CB-A bags on 197 infusion days (23.1%) in 43 infants (44.3%). More than 1 of these nutrients was added to the bag on only 1 perfusion day. Mean and maximum parenteral nutrient intakes were 2.8 ± 0.7 and 3.6 ± 0.8 g amino acids per kilogram per day, and 80 ± 20 and 104 ± 22 kcal · kg−1 · day−1. Mean weight gain represented 10.0, 21.5, and 22.6 g · kg−1 · day−1 according to age at inclusion (0–3, 4–7, or >7 days of life). A visual analog scale was completed and produced positive results. No adverse events were attributable to the design of the Ped3CB-A system. Conclusions: Ped3CB-A provides easy-to-use, well-balanced, and safe nutritional support. Nutritional intakes and weight gain were within the recent PN recommendations in preterm infants.

Determinants of body composition in preterm infants at the time of hospital discharge

BACKGROUND Preterm infants have a higher fat mass (FM) percentage and a lower fat-free mass (FFM) than do term infants at the time of hospital discharge. OBJECTIVE We determined perinatal and nutritional factors that affect the body composition of preterm infants at discharge. DESIGN A total of 141 preterm infants born at <35 wk of gestation and admitted to Nantes University Hospital Neonatology Unit over a period of 2 y were enrolled. Nutritional intake and growth were monitored during hospitalization. Body composition was assessed by using air-displacement plethysmography at discharge. FFM was compared with reference data in term infants according to sex and gestational age. RESULTS Linear regression produced an excellent model to predict absolute FFM from perinatal characteristics and nutrition (R(2) = 0.82) but not the FM percentage (R(2) = 0.24). Gestational and postnatal ages played an equal role in absolute FFM accretion, as did the initial growth (between birth and day 5) and growth between day 5 and discharge. Antenatal corticosteroid treatment slightly reduced FFM accretion. As concerns nutritional intake, a higher protein:energy ratio at days 10 and 21 was significantly associated with decreased risk of an FFM deficit when preterm infants were compared with reference values for term infants. Boys had higher risk of an FFM deficit than did girls. CONCLUSION The initial growth and quality of nutrition were significantly associated with absolute FFM accretion during a hospital stay in preterm infants. This trial was registered at clinicaltrials.gov as NCT01450436.

Calcium, Phosphorus, Magnesium and Vitamin D Requirements of the Preterm Infant

Proper mineral and vitamin D nutrition in preterm infants is essential for adequate bone health because preterm infants are at a risk of prematurely developing osteopenia. This chapter focuses on nutritional aspects of the requirements after a brief description of the perinatal physiology of minerals and vitamin D. The rationale for estimation of nutritional mineral requirements of the preterm infant (based upon estimates of the intrauterine skeletal accretion rate of minerals, and upon estimates of the coefficient of intestinal absorption) is first described. Previous expert recommendations are reviewed and compared to the present recommendations. Finally, vitamin D requirements are thoroughly reviewed based upon what is known of the physiology of vitamin D in preterm infants. A suggestion that each extremely preterm infant should be monitored for adequate vitamin D status is made.

Preterm infant growth velocity calculations: A systematic review

The many different methods used to calculate preterm infant growth velocity make comparisons between studies and with published values difficult if not impossible. CONTEXT: Clinicians assess the growth of preterm infants and compare growth velocity using a variety of methods. OBJECTIVE: We determined the numerical methods used to describe weight, length, and head circumference growth velocity in preterm infants; these methods include grams/kilogram/day (g/kg/d), grams/day (g/d), centimeters/week (cm/week), and change in z scores. DATA SOURCES: A search was conducted in April 2015 of the Medline database by using PubMed for studies that measured growth as a main outcome in preterm neonates between birth and hospital discharge and/or 40 weeks’ postmenstrual age. English, French, German, and Spanish articles were included. The systematic review was conducted by using Preferred Reporting Items for Systematic Reviews and Meta-analyses methods. STUDY SELECTION: Of 1543 located studies, 373 (24%) calculated growth velocity. DATA EXTRACTION: We conducted detailed extraction of the 151 studies that reported g/kg/d weight gain velocity. RESULTS: A variety of methods were used. The most frequently used method to calculate weight gain velocity reported in the 1543 studies was g/kg/d (40%), followed by g/d (32%); 29% reported change in z score relative to an intrauterine or growth chart. In the g/kg/d studies, 39% began g/kg/d calculations at birth/admission, 20% at the start of the study, 10% at full feedings, and 7% after birth weight regained. The kilogram denominator was not reported for 62%. Of the studies that did report the denominators, the majority used an average of the start and end weights as the denominator (36%) followed by exponential methods (23%); less frequently used denominators included birth weight (10%) and an early weight that was not birth weight (16%). Nineteen percent (67 of 355 studies) made conclusions regarding extrauterine growth restriction or postnatal growth failure. Temporal trends in head circumference growth and length gain changed from predominantly cm/wk to predominantly z scores. LIMITATIONS AND CONCLUSIONS The lack of standardization of methods used to calculate preterm infant growth velocity makes comparisons between studies difficult and presents an obstacle to using research results to guide clinical practice.

Electrolyte and mineral homeostasis after optimizing early macronutrient intakes in VLBW infants on parenteral nutrition

Objectives: The aim of the present study was to evaluate electrolyte and mineral homeostasis in very-low-birth-weight (VLBW) infants who received high protein and energy intakes with a unique standardized parenteral nutrition solution containing electrolytes and minerals from birth onward. Methods: Prospective cohort study in 102 infants with birth weight <1250 g. The evolution of plasma biochemical parameters was described during the first 2 weeks of life. Results: During the first 3 days of life, mean parenteral intakes were 51 ± 8 kcal · kg−1 · day−1 with 2.7 ± 0.4 g · kg−1 · day−1 of protein, 1.1 ± 0.2 mmol · kg−1 · day−1 of sodium and potassium, and 1.3 ± 0.2 mmol · kg−1 · day−1 of calcium and phosphorus. Afterwards, most nutritional intakes (parenteral and enteral) met growth requirements. No infant developed a hyperkalemia >7 mmol/L, and a hypernatremia >150 mmol/L occurred only in 15.7% of the infants. In contrast, hyponatremia <130 mmol/L and hypokalemia <3 mmol/L occurred in 30.4% and 8.8% of the infants, respectively. The initial neonatal metabolic acidosis rapidly resolved in most infants and only 2.0% developed a base deficit >10 mmol/L after day 3 of life. Early hypocalcemia <1.8 mmol/L occurred in 13.7% of the infants. In contrast, hypophosphatemia <1.6 mmol/L occurred in 37.3% and hypercalcemia >2.8 mmol/L occurred in 12.7% of the infants. Conclusions: Increasing early protein and energy intakes in VLBW infants in the first week of life improves electrolyte homeostasis. It also increases the phosphorus requirements with a calcium-to-phosphorus ratio ⩽1.0 (mmol/mmol) and the potassium and sodium requirements to avoid the development of a refeeding-like syndrome. These data suggest that the parenteral nutrition guidelines for VLBW infants for the first week of life need to be revised.

Use of donor milk in the neonatal intensive care unit

Own mothers milk is the first choice in feeding preterm infants and provides multiple short- and long-term benefits. When it is unavailable, donor human milk is recommended as the first alternative. Donor milk undergoes processing (i.e. pasteurization) to reduce bacteriological and viral contaminants but influences its bioactive properties with potentially fewer benefits than raw milk. However, there is no clinical evidence of health benefit of raw compared to pasteurized human milk, and donor milk maintains documented advantages compared to formula. Nutrient content of donor and own mothers milk fails to meet the requirements of preterm infants. Adequate fortification is necessary to provide optimal growth. There are significant challenges in providing donor milk for premature infants; therefore, specific clinical guidelines for human milk banks and donor milk use in the neonatal intensive care unit should be applied and research should focus on innovative solutions to process human milk while preserving its immunological and nutritional components. In addition, milk banks are not the only instrument to collect, process and store donor milk but represent an excellent tool for breastfeeding promotion.

Levels of silicon in maternal, cord and newborn serum and their relationship with those of zinc and copper

Background: Evidence of silicons importance to health has been gradually accumulating. Nevertheless, there are few studies comparing serum silicon levels in newborns with maternal levels. Likewise, little is known concerning the inter-relation between silicon and other trace elements. Objective: The present study evaluated maternal and newborn levels of serum silicon and their relation to those of zinc and copper. Methods: We measured serum silicon, copper, and zinc in 66 pregnant women, in the umbilical cord of their infants, and in 44 newborns, by atomic absorption spectrophotometry. All the samples were from fasted subjects. Results: Serum silicon level in term newborns (20.6 ± 13.2 &mgr;mol/L) was significantly higher than in umbilical cord (8.9 ± 3.5 &mgr;mol/L; P < 0.0001). Mean serum silicon level in maternal vein (7.7 ± 3.4 &mgr;mol/L) was lower than that in umbilical cord, although differences were not significant. We also found higher levels of zinc (P = 0.008) and lower levels of copper (P < 0.0001) in cord blood compared with maternal blood. Umbilical venous/maternal venous level ratios of zinc, copper, and silicon were 1.5 ± 0.5, 0.2 ± 0.1, and 1.3 ± 0.7, respectively. There was a positive correlation between silicon and zinc levels (r = 0.32), and a negative correlation between copper and zinc levels (r = −0.35). Conclusions: It seems that there is a positive gradient of silicon from the mother to her fetus. Silicon levels were higher in newborn than in cord blood, and correlated significantly with that of zinc but not copper. Additional investigations are needed to further define the role of silicon and its interaction with other trace elements during the perinatal period.

Parenteral nutrition in premature infants

Optimizing postnatal nutritional supply is a major challenge in premature infants despite recent studies evaluating how to improve early nutritional support. Severe cumulative nutritional deficits may occur with adverse consequences on both short- and long-term outcomes. Complete enteral feeding is frequently delayed in premature infants, and parenteral nutrition (PN) represents essential therapeutic option for these infants. Available recommendations suggest starting PN as soon as possible after birth and rapidly attaining adequate intakes with a well-balanced solution in order to promote anabolism, to improve clinical outcomes, and to avoid biological disorders. A minimum intake of 40–60 kcal/kg/day with 2–3 g/kg/day of amino acids, 1–2 g/kg/day of lipids, and sufficient minerals is now recommended for the first hours of life in all premature infants. After immediate postnatal adaptation, intakes should rapidly increase during the first week of life, up to 95–125 kcal/kg/day with about 3–4 g/kg/day amino acids, 3–4 g/kg/day of lipids and adequate amounts of electrolytes, minerals, trace elements, and vitamins. There is a wide range of variation in PN practices among the neonatal units. This chapter discusses the principal theoretical aspects of PN in premature infants, the recommendations, and the opportunity to routinely optimize nutritional support, especially in very premature infants.