Valentina Bozzetti

Metabolic Bone Disease in preterm newborn: an update on nutritional issues

Osteopenia, a condition characterised by a reduction in bone mineral content, is a common disease of preterm babies between the tenth and sixteenth week of life. Prematurely born infants are deprived of the intrauterine supply of minerals affecting bone mineralization.The aetiology is multifactorial: inadequate nutrients intake (calcium, phosphorus and vitamin D), a prolonged period of total parenteral nutrition, immobilisation and the intake of some drugs.The diagnosis of metabolic bone disease is done by biochemical analysis: low serum levels of phosphorus and high levels of alkaline phosphatase are suggestive of metabolic bone disease. The disease can remain clinically silent or presents with symptoms and signs of rachitism depending on the severity of bone demineralisation.An early nutritional intervention can reduce both the prevalence and the severity of osteopenia.This article reviews the pathophysiology of foetal and neonatal bone metabolism, focuses on the nutrient requirements of premature babies and on the ways to early detect and treat osteopenia.

Feeding issues in IUGR preterm infants.

Intra-uterine growth restriction (IUGR) is a severe and quite common problem in obstetrics. A condition of placental dysfunction can lead to a cardiovascular adaptation in the fetus characterized by a redistribution of cardiac output to maintain oxygen supply to the heart, adrenal glands and brain - the so-called brain sparing effect - at the expense of visceral organs (such as the gastrointestinal system). This condition may predispose IUGR infants to impaired gut function after birth. A higher incidence of necrotizing enterocolitis (NEC) is documented in IUGR preterm infants. Therefore, a common practice in neonatal intensive care units is to delay feeds to reduce the risk of feeding intolerance. Recent trials, however, have shown that early enteral feeding in IUGR infants is safe and it would appear, on the basis of the few available data, that breast milk could offer protection against NEC. This mini-review offers an update on feeding in IUGR infants. Future perspectives on the usefulness of Doppler and regional splanchnic and cerebral saturation monitoring for deciding when to start feeding are also provided.

Cerebral and somatic NIRS-determined oxygenation in IUGR preterm infants during transition.

Abstract Background: Fetal growth restriction (intra-uterine growth restriction [IUGR]) has a considerable impact on perinatal morbidity. Preterm IUGR infants are prone to impaired intestine function. Near-infrared spectroscopy (NIRS) has been used to monitor oxygenation status of the brain and of the intestine. Patients and methods: We conducted a prospective case–control study at our NICU in 20 preterm infants of whom 10 infants complicated by compared with 10 non-IUGR preterm infants. Splanchnic and cerebral regional oximetry values were measured with NIRS. Three hours of consecutive recordings were performed in the first 24 h of life, T0, and during the transitional period, T1. The cerebral/splanchnic oxygenation ratio, CSOR, (cerebral regional saturations [rScO2]/splanchnic regional saturations [rSsO2]) was also calculated. Results: Both in the IUGR and the non-IUGR infants, at T0 and T1 monitoring time-points, the rSO2 values were higher in the cerebral district when compared to those of the splanchnic area. Comparison of the NIRS parameters between the IUGR and non-IUGR infants at T0 showed no difference in rScO2, while rSsO2 was significantly lower in the IUGR group. At T1, rScO2 was significantly lower and rSsO2 higher in the IUGR group. Conclusions: Cerebral/splanchnic vascular adaptation of IUGR infants to the extra-uterine environment is characterized by a postnatal persistence of the brain sparing effect with reperfusion in the transitional period.

Evaluation of splanchnic oximetry, Doppler flow velocimetry in the superior mesenteric artery and feeding tolerance in very low birth weight IUGR and non-IUGR infants receiving bolus versus continuous enteral nutrition.

BackgroundIUGR infants are thought to have impaired gut function after birth, which may result in intestinal disturbances, ranging from temporary intolerance to the enteral feeding to full-blown NEC.In literature there is no consensus regarding the impact of enteral feeding on intestinal blood flow and hence regarding the best regimen and the best rate of delivering the enteral nutrition.Methods/designThis is a randomized, non-pharmacological, single-center, cross-over study including 20 VLBW infants.Inclusion criteria* Weight at birth ranging: 700–1501 grams* Gestational age up to 25 weeks and 6 days* Written informed consent from parents or guardiansExclusion criteria* Major congenital abnormality* Patients enrolled in other trials* Significant multi-organ failure prior to trial entry* Pre-existing cutaneous disease not allowing the placement of the NIRS’ probeIn the first 24 hours of life, between the 48th and 72nd hours of life, and during Minimal Enteral Feeding, all infants’ intestinal perfusion will be evaluated with NIRS and a Doppler of the superior mesenteric artery will be executed.At the achievement of an enteral intake of 100 mL/Kg/day the patients (IUGR and NON IUGR separately) will be randomized in 2 groups: Group A (n=10) will receive a feed by bolus (in 10 minutes); then, after at least 3 hours, they will receive the same amount of formula administered in 3 hours. Group B (n=10) will receive a feed administered in 3 hours followed by a bolus administration of the same amount of formula (in 10 minutes) after at least 3 hours.On the randomization day intestinal and cerebral regional oximetry will be measured via NIRS. Intestinal and celebral oximetry will be measured before the feed and 30 minutes after the feed by bolus during the 3 hours nutrition the measurements will be performed before the feed, 30 minutes from the start of the nutrition and 30 minutes after the end of the gavage. An evaluation of blood flow velocity of the superior mesenteric artery will be performed meanwhile. The infants of the Group A will be fed with continuous nutrition until the achievement of full enteral feeding. The infants of the Group B will be fed by bolus until the achievement of full enteral feeding.DiscussionEvaluations of intestinal oximetry and superior mesenteric artery blood flow after the feed may help in differentiating how the feeding regimen alters the splanchnic blood flow and oxygenation and if the changes induced by feeding are different in IUGR versus NON IUGR infants.Trial registration numberNCT01341236

A new genetic mutation in a patient with syndromic diarrhea and hepatoblastoma.

Hepatology, and Nutrition DOI: 10.1097/MPG.0b013e31825600c4 FIGURE 1. Microscopic findings. Semithin slide under optical microscope shows a short intestinal villus. FIGURE 2. Hair findings. Microscopic analysis of a hair shaft reveals abnormalities, including twisted hair (pili torti), longitudinal breaks, and cuticolar cell disruptions leading to the separation and fragmentation of the cortical fibers with the formation of nodes. These features are pathognomonic of trichorFIGURE 3. Postmortem liver histology. A small hepatic nodule showing macrotrabecular structure, resembling a degeneration area of hepatoblastoma and cirrhosis.

Feeding tolerance of preterm infants appropriate for gestational age (AGA) as compared to those small for gestational age (SGA).

Abstract Preterm infants are often considered too unstable to be fed enterally so they are exposed to complications related to a prolonged enteral fasting. Our study aims to compare feeding tolerance of adequate for gestational age (AGA) versus small for gestational age (SGA) infants and to evaluate which perinatal factors affect feeding tolerance (measured as time to achieve full enteral feeding, FEF). Inborn infants with a gestational age (GA) less than 32 weeks, born from January 2006 to December 2010, were eligible for this study. We enrolled 310 infants. The time to FEF was longer for SGA infants than for AGA, while a longer GA was associated to a reduced time to FEF. A beneficial effect was observed for antenatal steroids, while Apgar score below 7, the administration of inotrops or caffeine, the occurrence of sepsis or NEC and the presence of PDA were associated to a longer time to FEF. When evaluated jointly with a multivariate analysis, GA (p < 0.0001), antenatal steroids prophylaxis (p = 0.002), SGA (p < 0.0001) and occurrence of NEC (p = 0.0002) proved to have independent prognostic impact on the time to FEF. Feeding tolerance is better as GA increases, and worsen in SGA infants. Antenatal betamethasone is effective in reducing the time to FEF in both AGA and SGA.

Monitoring Doppler patterns and clinical parameters may predict feeding tolerance in intrauterine growth‐restricted infants

To detect predictors of feeding tolerance in intrauterine growth restriction (IUGR) infants with or without brain‐sparing effect (BS).

Nutritional approach to preterm infants on noninvasive ventilation: An update

Nutrition and pulmonary function in very-low-birth-weight infants (VLBWIs) are strictly related. Preterm infants on noninvasive ventilation may have respiratory instability that can interfere with feeding tolerance. Moreover, feeding may impair pulmonary function. These infants have nutritional requirements different from nonventilated infants. The main challenge of the nutritional support in such patients is to guarantee adequate caloric intake while avoiding episodes of feeding intolerance. The aim of this study was to review the issues and strategies of enteral feeding of preterm infants on noninvasive ventilation.

Enteral nutrition for preterm infants: by bolus or continuous? An update

Optimization of nutritional management of preterm infants is crucial for achievement of their long-term health. Enteral nutrition is preferred to total parenteral nutrition (TPN) because the former avoids complications related to vascular catheterization, sepsis, adverse effects of TPN, and fasting. Due to the lack of ability of preterm infants to coordinate suckling, swallowing, and breathing, tube feeding is necessary for most infants less than 1500 g to ensure sufficient feeding tolerance, to support optimal growth and to reduce the risk of aspiration. Therefore, feeding by orogastric or nasogastric tube using either continuous or intermittent bolus delivery of formula or human milk is common practice for these infants. Theoretical risks and benefits of both continuous nasogastric milk feeding and intermittent bolus milk feeding have been proposed. According to the literature, continuous nutrition could be preferred in smaller infants (as those with a birthweight below 1250 g) or hemodynamically impaired infants; in stable growing infants nutrition can be administered intermittently as in healthy term infants.

Enteral feeding of intrauterine growth restriction preterm infants: theoretical risks and practical implications

Intrauterine growth restriction (IUGR) infants are thought to have impaired gut function after birth secondary to intrauterine redistribution of the blood flow, due to placental insufficiency, with a consequent reduction of gut perfusion. For this reason, infants complicated by IUGR have been considered at higher risk of feeding intolerance. Postnatal evaluation of splanchnic perfusion, through Doppler of the superior mesenteric artery, and of splanchnic oxygenation, through near infrared spectroscopy measurements, may be useful in evaluating the persistence (or not) of the redistribution of blood flow occurred in utero.