Duration Of Parenteral Nutrition Research Articles

Do Patients With a Baseline Clinical Condition Warranting the Cautious Use of Parenteral Nutrition Develop Subsequent Metabolic Complications?

The American Society for Parenteral and Enteral Nutrition Adult Nutrition Support Core Curriculum describes clinical conditions that warrant cautious use of parenteral nutrition (CCWCPN). The Core Curriculum authors acknowledge there is no evidence for specific criteria suggested for the clinical conditions. Consequently, the purpose of this study was to determine the impact of a baseline CCWCPN on the development of subsequent metabolic complications in patients receiving parenteral nutrition (PN). Adult patients initiated on PN from May 2014 to July 2015 at Cooper University Hospital were included in this retrospective study. The impact of a CCWCPN on the development of the following was determined: acid-base disturbances, hepatobiliary complications, hypercapnia, hyperchloremia, hyperglycemia, hypernatremia, hypertriglyceridemia, hypochloremia, hypoglycemia, hypokalemia, hypophosphatemia, and refeeding syndrome. Three hundred forty-one patients were included (mean age, 61.7 years; mean duration of PN, 8.5 days; central PN, 97%). Metabolic complications occurred more frequently in patients with a baseline CCWCPN than without these conditions (77% vs 53%, P = .001). Subgroup analyses for the development of metabolic complications in patients with or without each individual baseline CCWCPN yielded the following statistically significant results: hypernatremia (93% vs 57%, P = .007) and hyperchloremia (86% vs 57%, P = .033). Hospitalized adult patients with a baseline CCWCPN were more likely to develop a metabolic complication when receiving PN. Baseline hypernatremia and hyperchloremia were associated with the development of metabolic complications. Baseline CCWCPN should be recognized upon initiation of PN; practitioners should closely monitor patients to minimize subsequent metabolic complications.

Oral stimulation for promoting oral feeding in preterm infants.

Preterm infants (< 37 weeks' postmenstrual age) are often delayed in attaining oral feeding. Normal oral feeding is suggested as an important outcome for the timing of discharge from the hospital and can be an early indicator of neuromotor integrity and developmental outcomes. A range of oral stimulation interventions may help infants to develop sucking and oromotor co-ordination, promoting earlier oral feeding and earlier hospital discharge. To determine the effectiveness of oral stimulation interventions for attainment of oral feeding in preterm infants born before 37 weeks' postmenstrual age (PMA).To conduct subgroup analyses for the following prespecified subgroups.• Extremely preterm infants born at < 28 weeks' PMA.• Very preterm infants born from 28 to < 32 weeks' PMA.• Infants breast-fed exclusively.• Infants bottle-fed exclusively.• Infants who were both breast-fed and bottle-fed. We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via PubMed (1966 to 25 February 2016), Embase (1980 to 25 February 2016) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 25 February 2016). We searched clinical trials databases, conference proceedings and the reference lists of retrieved articles. Randomised and quasi-randomised controlled trials comparing a defined oral stimulation intervention with no intervention, standard care, sham treatment or non-oral intervention in preterm infants and reporting at least one of the specified outcomes. One review author searched the databases and identified studies for screening. Two review authors screened the abstracts of these studies and full-text copies when needed to identify trials for inclusion in the review. All review authors independently extracted the data and analysed each study for risk of bias across the five domains of bias. All review authors discussed and analysed the data and used the GRADE system to rate the quality of the evidence. Review authors divided studies into two groups for comparison: intervention versus standard care and intervention versus other non-oral or sham intervention. We performed meta-analysis using a fixed-effect model. This review included 19 randomised trials with a total of 823 participants. Almost all included trials had several methodological weaknesses. Meta-analysis showed that oral stimulation reduced the time to transition to oral feeding compared with standard care (mean difference (MD) -4.81, 95% confidence interval (CI) -5.56 to -4.06 days) and compared with another non-oral intervention (MD -9.01, 95% CI -10.30 to -7.71 days), as well as the duration of initial hospitalisation compared with standard care (MD -5.26, 95% CI -7.34 to -3.19 days) and compared with another non-oral intervention (MD -9.01, 95% CI -10.30 to -7.71 days).Investigators reported shorter duration of parenteral nutrition for infants compared with standard care (MD -5.30, 95% CI -9.73 to -0.87 days) and compared with another non-oral intervention (MD -8.70, 95% CI -15.46 to -1.94 days). They could identify no effect on breast-feeding outcomes nor on weight gain. Although the included studies suggest that oral stimulation shortens hospital stay, days to exclusive oral feeding and duration of parenteral nutrition, one must interpret results of these studies with caution, as risk of bias and poor methodological quality are high overall. Well-designed trials of oral stimulation interventions for preterm infants are warranted. Such trials should use reliable methods of randomisation while concealing treatment allocation, blinding caregivers to treatment when possible and paying particular attention to blinding of outcome assessors.

Aggressive nutrition in extremely low birth weight infants: impact on parenteral nutrition associated cholestasis and growth

BackgroundParenteral nutrition associated cholestasis (PNAC) is a frequently observed pathology in extremely low birth weight (ELBW) infants. Its pathogenesis is determined by the composition and duration of parenteral nutrition (PN) as well as the tolerance of enteral feeds (EF). “Aggressive” nutrition is increasingly used in ELBW infants to improve postnatal growth. Little is known about the effect of “aggressive” nutrition on the incidence of PNAC. We analyzed the influence of implementing an “aggressive” nutritional regimen on the incidence of PNAC and growth in a cohort of ELBW infants.MethodsELBW infants were nourished using a “conservative” (2005–6; n = 77) or “aggressive” (2007–9; n = 85) nutritional regimen that differed in the composition of PN after birth as well as the composition and timing of advancement of EFs. We analyzed the incidence of PNAC (conjugated bilirubin > 1.5 mg/dl (25 µmol/l)) corrected for confounders of cholestasis (i.e., NEC and/or gastrointestinal surgery, sepsis, birth weight, Z-score of birth weight, time on PN and male sex), growth until discharge (as the most important secondary outcome) and neonatal morbidities.ResultsThe incidence of PNAC was significantly lower during the period of “aggressive” vs. “conservative “nutrition (27% vs. 46%, P < 0.05; adjusted OR 0.275 [0.116–0.651], P < 0.01). Body weight (+411g), head circumference (+1 cm) and length (+1 cm) at discharge were significantly higher. Extra-uterine growth failure (defined as a Z-score difference from birth to discharge lower than −1) was significantly reduced for body weight (85% vs. 35%), head circumference (77% vs. 45%) and length (85% vs. 65%) (P < 0.05). The body mass index (BMI) at discharge was significantly higher (11.1 vs. 12.4) using “aggressive” nutrition and growth became more proportionate with significantly less infants being discharged below the 10th BMI percentile (44% vs. 9%), while the percentage of infants discharged over the 90th BMI percentile (3% vs. 5%) did not significantly increase.Discussion“Aggressive” nutrition of ELBW infants was associated with a significant decrease of PNAC and marked improvement of postnatal growth.

The Timing of Stoma Closure in Infants with Necrotizing Enterocolitis: A Systematic Review and Meta-Analysis.

Aim Some infants with necrotizing enterocolitis (NEC) undergoing surgery require the formation of a stoma. The timing of stoma closure in these patients remains controversial. Our aim was to determine whether the different timing of closure had an impact on patient outcome. Methods Using a defined search strategy (PubMed, Embase, and Web of Science), two investigators (Q.L. and G.L.) independently identified studies comparing early stoma closure (ESC, before 8 weeks from stoma formation) versus late stoma closure (LSC, after 8 weeks) in infants with NEC. Outcome measures included the duration of parenteral nutrition, the length of hospital stay, and complications. Meta-analysis was performed using RevMan 5.3 (The Cochrane Collaboration, Copenhagen, Denmark). Data are expressed as mean ± standard deviation. Results Of the 505 articles screened, 6 articles met the inclusion criteria (280 infants). All studies but one were retrospective. The total duration on parenteral nutrition was similar in infants with ESC versus LSC, and the total length of hospital stay (pre- plus poststoma closure) was not influenced by the timing of stoma closure. Three studies (79 infants) reported similar complication rates after stoma closure between ESC (5/16, 31%) and LSC infants (13/63, 19%; p = 0.5). Conclusions This systematic review demonstrates that there is no difference between different timings for stoma closure in post-NEC infants. With the current supporting evidence, ESC seems to be as safe and feasible as LSC. Studies with a higher level of evidence are needed to confirm these conclusions.

Excessive Postoperative Fluid Administration in Infants with Gastroschisis

Careful fluid management is a cornerstone of neonatology because the cardiovascular, respiratory, and gastrointestinal systems in the newborn are sensitive to overhydration. Fluid management in gastroschisis is complicated by insensible fluid loss and postoperative third-space fluid shifts. Study of perioperative fluid management in gastroschisis is limited and has not undergone careful scrutiny. We reviewed perioperative fluid administration and urine output in all infants with gastroschisis over a 5-year period. Data included whether the patient underwent primary closure or staged repair, weight, and events during hospitalization (length of hospitalization and duration of gastric decompression, parenteral nutrition, and ventilator support). Paired t test gave statistical comparisons with significance at P < 0.05. From 2010 to 2014, 24 patients underwent abdominal closure, 17 had primary and 7 had staged closures. Fluid administration exceeded 100 mL/kg/d after primary closure, and was significantly higher (>150 mL/kg/d; P < 0.05) after staged closure on postoperative days 0 to 5. Postoperative urinary output exceeded 75 mL/kg/d for all patients, with higher volumes reaching 100 mL/kg/d after staged closure on postoperative days 4 to 6 (P < 0.05). Two patients died of sepsis. All survivors were discharged with intestinal continuity and gaining weight on oral feeding. Patients with gastroschisis received large volumes of fluid after operation despite similarly high urine output and positive daily fluid balances. The amounts of fluid administered after both primary and staged closure may be excessive and potentially deleterious.

Colonisation à levures chez les prématurés de moins de 1500 g hospitalisés en réanimation néonatale

Fungal colonization is a common occurrence in preterm neonates. Our objective was to describe the profile and characteristics of fungal colonization in preterm infants admitted to the Martinique NICU. From March 2012 to January 2013, an epidemiological prospective cohort study was conducted with 57 very low-birth-weight infants. Cutaneous, rectal, gastric, respiratory, and urinary swabs were collected on admission, then every week for 4 weeks. The prevalence of fungal colonization was 68% (39/57): 46% by Malassezia species, 28% by Candidaparapsilosis, 19% by C.albicans, 5% by C.glabrata, and 2% by C.guilliermondii. The colonized patients had a duration of parenteral nutrition and antibiotic therapy longer than the others (P<0.05). Nosocomial colonization (after 2 days of life) occurred in 52% of cases: Malassezia species and C.parapsilosis were the commensal skin yeasts most frequently implicated. Forty-nine percent (28/57) had suspected invasive fungal infections that received probabilistic treatment. Only one case of invasive fungal infection with C.glabrata was diagnosed. This study highlights the important role played by nosocomial transmission in the colonization of preterm newborns. Mycological surveillance cultures in the NICU are very useful for monitoring fungal ecology and can improve the prevention of fungal colonization in preterm infants at risk of invasive fungal infection.

Outcomes of infants with abdominal wall defects over 18 years

Background/PurposeInfants with abdominal wall defects (AWD) are at risk of poor outcomes including prolonged hospitalization, infections and mortality. Our objective was to describe and compare the outcomes of infants admitted with gastroschisis and omphalocele over 18years. MethodsPopulation-based study of clinical data and outcomes of live-born infants with AWD admitted to all tertiary-level neonatal intensive care units in New South Wales and Australian Capital Territory from 1992 to 2009. ResultThere were 502 infants with AWD – 336 gastroschisis, 166 omphalocele. Infants with gastroschisis required a longer duration of total parenteral nutrition (19 vs 4days, p<0.05), longer hospitalization (28 vs 15days, p<0.05) and had a higher rate of systemic infection [23.5% vs 13.3%, OR 1.77 (1.15–2.74), p<0.05] compared to infants with omphalocele. Overall, omphalocele infants had higher mortality rate compared to gastroschisis infants [OR 2.77 (1.53, 5.04), p<0.05]. Gastroschisis mortality rates increased from epoch 1 to epoch 3 (4.2% to 8.8%). ConclusionCompared to infants with omphalocele, infants with gastroschisis required significantly longer hospitalization and parenteral nutrition with higher rates of infection. Infants with omphalocele had higher overall mortality rates. However, there has been an increase in the gastroschisis mortality rates but the cause for this is unclear.

Randomized Control Trial of Human Recombinant Lactoferrin: A Substudy Reveals Effects on the Fecal Microbiome of Very Low Birth Weight Infants

The purpose of this study is to evaluate the effects of enteral lactoferrin on the fecal microbiome and contrast those influences with the neonatal intensive care unit (NICU) environment. We theorized that lactoferrin and the NICU habitat shape the fecal microbial composition of very preterm infants. Although functions attributed to lactoferrin include intestinal immune system development and emergence of a healthy gut microbiota, evidence is limited. Twenty-one very low birth weight (VLBW <1500g) infants received twice-daily talactoferrin (TLf, a drug designation for recombinant human lactoferrin) or its excipient by gastric gavage from day 1-28 of life. Twenty-four-hour fecal samples were collected on day 21 of life and compared with fecal operational taxonomy units (OTUs) in treated and control infants in 2 NICUs. Workflow included fecal DNA isolation, generation of amplicons for the V1-V3 region of bacterial 16S ribosomal RNA, and sequencing of a gel-purified multiplex amplicon library using a Roche 454 GS FLX Titanium (Roche, Branford, Connecticut) platform and protocols. Fecal OTUs per infant were higher in NICU 1 vs NICU 2 (P<.001), consistent with fewer antibiotic days (P<.02) and a shorter duration of parenteral nutrition (P<.007) in NICU 1. Proteobacteria and Firmicutes were the major phyla in infants treated with TLf and placebo. Among Enterobacteriaceae, TLf prophylaxis reduced Enterobacter and Klebsiella, but increased Citrobacter in feces of VLBW infants. Citrobacter caused no neonatal infections in the study population. OTUs for Clostridiaceae increased in NICU 1 among infants treated with TLf. Importantly, OTUs of staphylococci were barely detectable in both NICUs among infants fed TLf. Fewer hospital-acquired infections occurred in infants treated with TLf vs controls, although the reduction was seen mostly in coagulase-negative staphylococci-related bloodstream and central line infections (P=.06). TLf modified the fecal microbiome in VLBW infants, but care practices in the NICU habitat also contributed. Future research must establish whether elimination vs enrichment of gut-related microbiota reduces clinically significant hospital-acquired infections and promotes a healthy commensal microflora in the intestines of VLBW infants. ClinicalTrials.gov: NCT00854633.

Risk factor analysis of parenteral nutrition-associated cholestasis in extremely low birth weight infants.

Parenteral nutrition (PN) provides an alternative nutrition source for preterm infants who are intolerant of enteral nutrition. However, prolonged PN increases the risk of PN-associated cholestasis (PNAC). We conducted this study to determine the incidence and risk factors of PNAC in extremely low birth weight (ELBW) infants. We retrospectively reviewed the medical records of ELBW infants from March 2010 to April 2015. PNAC was diagnosed in infants with a history of PN for at least two weeks and direct bilirubin concentrations >2 mg/dL after other causes of neonatal cholestasis were excluded. Of the 114 eligible ELBW infants, 41 (36%) were diagnosed with PNAC. The multivariate analysis showed that birth weight, sepsis, necrotising enterocolitis, fluconazole prophylaxis and the duration of PN and hospitalisation were independent risk factors for the development of PNAC (p < 0.05). However, parenteral fish oil-based lipid preparation (FOLP) did not reduce the risk of PNAC. Although PNAC was not a direct cause of death, it was associated with an increased risk of mortality. PNAC was common in ELBW infants, was associated with various clinical factors and increased the risk of mortality. However, we did not observe the protective effect of FOLP against PNAC.

Risk Factors for Healthcare Associated Sepsis in Very Low Birth Weight Infants

Healthcare associated infections in very low birth weight infants are associated with significant morbidity and mortality and are also a cause of increased length of stay and hospital costs. The objective of this study was to evaluate the rate of healthcare-associated sepsis and associated risk factors in very low birth weight infants. Retrospective observational study including very low birth weight infants hospitalized in a Neonatal Intensive Care Unit during ten years (2005-2014). We evaluated the association between several risk factors and healthcare-associated sepsis. 461 very low birth weight infants were admitted. There were 110 episodes of HS in 104 very low birth weight infants and 53 episodes of sepsis associated with central vascular catheter. The density of the sepsis was 7.5/1 000 days of hospitalization and the density of central vascular catheter - associated sepsis was 22.6/1 000 days of use. The infants with HS had lower average birth weight and gestational age (959 ± 228 g vs 1191 ± 249 g and 27.6 ± 2 vs 29.8 ± 2.2 weeks), p < 0.001. After adjusting for birth weight and gestational age we verified an association between healthcare-associated sepsis and antibiotic therapy in D1, the duration of parenteral nutrition and central vascular catheter. After logistic regression only the gestational age and duration of parenteral nutrition remained as independent significant risk factors for healthcare-associated sepsis. The independent factors for healthcare-associated sepsis are gestational age and duration of parenteral nutrition. For each extra week on gestational age the risk declined in 20% and for each day of NP the risk increased 22%.

Ventilator-Associated Pneumonia in Low Birth Weight Neonates at a Neonatal Intensive Care Unit: A Retrospective Observational Study

Ventilator-associated pneumonia (VAP) is one of the most common healthcare-associated infections among ventilated patients. The aim of this study was to determine the clinical characteristics and risk factors for the development of VAP in intubated low birth weight (LBW) neonates in a neonatal intensive care unit. LBW infants (<2.5kg) admitted to the neonatal intensive care unit of Kaohsiung Medical University Hospital from January 2005 to December 2009 were enrolled. We retrospectively analyzed perinatal and neonatal data of the enrolled intubated LBW infants by chart review. Six hundred and five LBW infants were analyzed. One hundred and fourteen of the infants were intubated for >48hours, 15 (13.2%) of whom had VAP. Of these 15 patients, the average age at onset of VAP was 24.0±11.2days, the average postmenstrual age was 30.6±1.8weeks, and the mean gestational age was 27.1±2.3weeks, which was significantly lower than the mean gestational age in the group without VAP (30.2±3.5weeks). The mean birth body weight was 944.4±268.4g in the VAP group and 1340.1±455.4g in the group without VAP (p<0.001). Longer duration of intubation (odds ratio: 1.35, 95% confidence interval: 1.12-1.62) and parenteral nutrition (odds ratio: 1.32, 95% confidence interval: 1.14-1.51) were found in the VAP group after adjusting for gestational age and birth weight. VAP was a problem for the LBW infants with intubation for >48hours in ourneonatal intensive care unit. VAP most frequently occurred at a postmenstrual age of 30-32weeks in this study. Longer duration of tube placement and parenteral nutrition were found in the VAP group. Early removal of the endotracheal tube and adequate enteral nutrition may decrease the occurrence of VAP in LBW infants.

Effects of Xuanbai Chengqi decoction on lung compliance for patients with exogenous pulmonary acute respiratory distress syndrome.

ObjectiveTo observe the effects of Xuanbai Chengqi decoction on lung compliance for patients with exogenous pulmonary acute respiratory distress syndrome.Subjects and methodsA total of 53 patients with exogenous pulmonary acute respiratory distress syndrome, who were admitted to the intensive care unit of the First Affiliated Hospital of Henan University of Traditional Chinese Medicine from March 2009 to February 2013, were selected. They were randomly divided into the treatment group (25 cases) and the control group (28 cases). Both the groups were treated with conventional treatment and lung-protective ventilation strategy; apart from these, enema therapy with Xuanbai Chengqi decoction was given to the treatment group. Meanwhile, static lung compliance, dynamic lung compliance, peak airway pressure, plateau pressure, and positive end-expiratory pressure (PEEP) for patients in both the groups were observed and recorded at 24, 48, and 72 hours after the drug was used. Moreover, variations in the duration of parenteral nutrition, incidence rate of complications, and case fatality rate in patients after treatment were recorded.ResultsFor patients in the treatment group, at 48 and 72 hours after treatment, the static lung compliance and dynamic lung compliance were significantly higher than those in the control group, while plateau pressure, peak airway pressure, and PEEP were significantly lower than those before treatment. At the same time, PEEP for patients in the treatment group at 72 hours after treatment was remarkably lower than that in the control group, showing significant difference (P<0.05). The duration of parenteral nutrition in the treatment group was significantly shorter than that in the control group (P<0.05). Both the incidence rate and the fatality rate of complications, such as abdominal distension and ventilator-associated pneumonia, for patients in the treatment group were distinctly smaller than those in the control group (P<0.05).ConclusionXuanbai Chengqi decoction not only can improve the static lung compliance and dynamic compliance of patients with exogenous pulmonary distress syndrome but also can shorten the parenteral nutrition duration, as well as reducing the complication incidence rate and fatality rate.

The Effect of Fish Oil-Based Lipid Emulsion and Soybean Oil-Based Lipid Emulsion on Cholestasis Associated with Long-Term Parenteral Nutrition in Premature Infants.

Purpose. To retrospectively study the effect of fish oil-based lipid emulsion and soybean oil-based lipid emulsion on cholestasis associated with long-term parenteral nutrition in premature infants. Methods. Soybean oil-based lipid emulsion and fish oil-based lipid emulsion had been applied in our neonatology department clinically between 2010 and 2014. There were 61 qualified premature infants included in this study and divided into two groups. Soybean oil group was made up of 32 premature infants, while fish oil group was made up of 29 premature infants. Analysis was made on the gender, feeding intolerance, infection history, birth weight, gestational age, duration of parenteral nutrition, total dosage of amino acid, age at which feeding began, usage of lipid emulsions, and incidence of cholestasis between the two groups. Results. There were no statistical differences in terms of gender, feeding intolerance, infection history, birth weight, gestational age, duration of parenteral nutrition, total dosage of amino acid, and age at which feeding began. Besides, total incidence of cholestasis was 21.3%, and the days of life of occurrence of cholestasis were 53 ± 5.0 days. Incidence of cholestasis had no statistical difference in the two groups. Conclusion. This study did not find the different role of fish oil-based lipid emulsions and soybean oil-based lipid emulsions in cholestasis associated with long-term parenteral nutrition in premature infants.

Parenteral Nutrition in Hospitalized Children

Objective: Parenteral Nutrition (PN) is prescribed to children with a non functioning gut or to those who fail to meet their nutritional requirements enterally. Complications should be balanced against the benefit for the patient. The aim of this study was to establish if the indications for PN prescribing in a tertiary referral children’s hospital were appropriate. Study Design: Children and newborns (infants <4 weeks of age) receiving inpatient PN between October 2013 and March 2014 were enrolled and data was collected prospectively. The appropriate indications for the use of PN were based on the 2005 guidelines by the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). Results: 303 children (67 newborns) were enrolled. Patients were referred from different departments across the hospital. The median duration of PN was 18 days (1-160). PN was mainly prescribed to critically ill children on intensive care (66/303), those ungergoing surgery (63/303) and bone marrow transplantation (28/303). The ESPGHAN recommendations were followed in 91.7% (278/303) of cases (newborns 64/67, 95.5%; children 214/236, 90.8%). The use of PN was considered inappropriate in 12/303 patients and in 13/303 it was not possible to reach a conclusion. Conclusion: Although the indications for inpatient PN in children is mostly justified, there is still a proportion of patients receiving intravenous nutrition unnecessarily highlighting the need for more PN training and better access to nutritional support teams.

Parenteral Nutrition-Associated Cholestasis in Very Low Birth Weight Infants: A Single Center Experience.

PurposeParenteral nutrition (PN)-associated cholestasis (PNAC) is one of the most common complications in very low birth weight infants (VLBWIs). The aim of this study is to evaluate the risk factors of PNAC in VBLWIs.MethodsWe retrospectively reviewed the medical records of 322 VLBWIs admitted to the neonatal intensive care unit of our hospital from July 1, 2009 to December 31, 2013. We excluded 72 dead infants; 6 infants were transferred to another hospital, and 57 infants were transferred to our hospital at 2 weeks after birth. The infants were divided into the cholestasis and the non-cholestasis groups. PNAC was defined as a direct bilirubin level of ≥2.0 mg/dL in infants administered with PN for ≥2 weeks.ResultsA total of 187 VLBWI were enrolled in this study; of these, 46 infants developed PNAC. Multivariate logistic regression analysis showed that the risk factors of PNAC in VLBWI were longer duration of antimicrobial use (odds ratio [OR] 4.49, 95% confidence interval [95% CI] 4.42-4.58), longer duration of PN (OR 2.68, 95% CI 2.41-3.00), long-term lack of enteral nutrition (OR 2.89, 95% CI 2.43-3.37), occurrence of necrotizing enterocolitis (OR 2.40, 95% CI 2.16-2.83), and gastrointestinal operation (OR 2.19, 95% CI 2.03-2.58).ConclusionThe results of this study suggest that shorter PN, aggressive enteral nutrition, and appropriate antimicrobial use are important strategies in preventing PNAC.

Factors Conducive to Catch-Up Growth in Postoperative Jejunoileal Atresia Patients as Prognostic Markers of Outcome.

Jejunoileal atresia (JIA) is a major congenital anomaly that requires surgical intervention in the neonatal period. During follow-up after surgery, there is usually a period of catch-up growth (CUG) that is sufficient for patients to regain normal weight for age. However, in some cases, CUG is inadequate. The aim of this study was to assess postoperative JIA patients to determine factors that may be associated with good CUG. We retrospectively reviewed JIA patients treated at our institution by classifying them into three groups based on a comparison of postoperative weight with standard weight for healthy matched controls; that is, more than mean at 12 months after surgery (group M+), less than mean at 12 months after surgery but more than mean at 24 months after surgery because of CUG (group M-CUG+), less than mean at 24 months after surgery because there was no CUG (group M-CUG-). The following parameters were evaluated: gestational age, birth weight, sight of atresia: jejunum or ileum, length of residual small intestine, ratio of the length of residual small intestine to the predicted length of small intestine for matched gestational age (RP ratio), and duration of parenteral nutrition. A total of 42 patients were reviewed and classified into group M+ (n = 13), group M-CUG+ (n = 11), and group M-CUG- (n = 18). There were no significant differences in gestational age, birth weight, and duration of parenteral nutrition between the three groups. Incidence of JIA according to site was also similar. Length of residual small intestine was not significantly different between the three groups, but RP ratios were significantly higher in M+ (84.7 ± 15.4%) and M-CUG+ (83.8 ± 17.7%) compared with M-CUG- (69.2 ± 18.1%) (p = 0.02, respectively). A higher RP ratio (approximately 84%) would appear to be conducive to CUG while a lower ratio (less than 70%) was not. Actual length of residual small intestine was not relevant to CUG. We recommend calculating the RP ratio in postoperative JIA patients and using 70% as a cutoff value to predict patients with poor potential for CUG who may benefit from more aggressive nutritional support to achieve normal growth.

Nutritional status of premature neonates fed with extensively hydrolyzed protein formula

Objective To analyze the nutritional status of premature neonates first fed with extensively hydrolyzed protein formula. Methods From January 2013 to December 2014, 157 premature neonates hospitalized in Neonatal Intensive Care Unit of Shanghai Children's Medical Center who were first fed with extensively hydrolyzed protein formula were enrolled. Clinical data were recorded, including related diseases, birth weight and gestational age, nutrients intake, and growth charts. Two groups were divided according to the existence or absence of feeding intolerance, and three groups were divided based on birth weight (<1 500 g, 1 500~2 500 g, and ≥2 500 g). Results A total of 60 (38.2%) premature infants had feeding intolerance. The lower the birth weight and gestational age, the higher the frequency of feeding intolerance, and the incidence of feeding intolerance in <1 500 g group was 71.1%. Compared with the feeding tolerance group, the feeding intolerance group had significantly smaller birth weight [(1 620±440)g vs. (1 980±421)g, P=0.000], gestational age [ (31.3±2.6)weeks vs. (33.0±2.1)weeks, P=0.000], birth head circumference [(28.9±2.2)cm vs. (30.4±1.9)cm, P=0.000], and birth length [(41.1±3.9)cm vs. (43.2±3.4)cm, P=0.000], but significantly longer time before transfer formula [(26.4±17.6)d vs. (7.9±5.3)d, P=0.000] and time before reaching sufficient feeding [(21.5±10.0)d vs. (13.8±6.2)d, P=0.000]. The time of first feeding [<1 500 g group (6.1±5.1)d, 1 500~2 500 g group (3.8±2.5)d, ≥2 500 g group (3.3±1.2)d, P=0.002], time before transfer formula [<1 500 g group (28.7±18.3)d, 1 500~2 500 g group (9.7±8.1)d, ≥2 500 g group (7.0±3.8)d, P=0.000] and time before reaching sufficient feeding [<1 500 g group (24.0±10.4)d, 1 500~2 500 g group (14.3±6.0)d, ≥2 500 g group (11.4±3.5)d, P=0.000] increased along with the decrease of birth weight. The proportions of infants receiving parenteral nutrition in the feeding intolerance group (93.3%) and <1 500 g group (97.8%) were higher, with more calorie intake from parenteral nutrition [<1 500 g group (325.9±59.4)kJ/(kg·d), 1 500~2 500 g group (281.2±64.8)kJ/(kg·d), ≥2 500 g group (269.9±43.9)kJ/(kg·d), P=0.001] and longer duration [<1 500 g group (27.1±14.5)d, 1 500~2 500 g group (13.0±7.0)d, ≥2 500 g group (8.7±3.4)d, P=0.000]. In terms of growth indicators, the increase in head circumference was significantly higher in the feeding intolerance group than in the feeding tolerance group [(0.7±0.6)cm/week vs. (0.6±0.5)cm/week, P=0.045]. The increases in body weight and head circumference in the <1 500 g group were significantly higher than in the other 2 birth weight groups [body weight: <1 500 g group (21.8±9.5)g/d, 1 500~2 500 g group (4.2±7.6)g/d, ≥2 500 g group (4.9±11.9)g/d, P=0.000; head circumference: <1 500 g group (0.8±0.4)cm/week, 1 500~2 500 g group (0.5±0.4)cm/week, ≥2 500 g group (0.6±0.8)cm/week, P=0.005]. After controlling the variable of feeding intolerance, weight gain was negatively associated with gestational age (r=-0.666, P=0.035), birth weight (r=-0.700, P=0.024), head circumference (r=-0.846, P=0.002), and the day of returning to birth weight (r=-0.697, P=0.025), while positively associated with head circumference gain (r=0.672, P=0.033). There were no relationship between weight gain and birth length, the day of first feeding, time before transfer formula, time before reaching sufficient feeding, parenteral nutrition calorie and duration, days of hospital stay and complications. Conclusions First fed with extensively hydrolyzed protein formula, the growth in feeding intolerant premature infants may be similar to the feeding tolerant ones, which is associated with parenteral nutrition support. Premature infants with lower gestational age, birth weight, and head circumference may be more suitable for extensively hydrolyzed protein formula feeding. Key words: Extensively hydrolyzed protein formula; Premature; Nutrition

Oxygen and parenteral nutrition two main oxidants for extremely preterm infants: 'It all adds up'.

To assess the effect of early exposure to O2 and parenteral nutrition (PN) on oxidative stress at 36 weeks post-menstrual age (PMA) and on bronchopulmonary dysplasia (BPD) in extremely preterm infants. A prospective observational study including 116 infants <29 weeks of gestation. Baseline clinical characteristics, FiO2 on day 7, duration of PN and clinical outcomes data were collected. In 39 infants, whole blood glutathione (GSH) and oxidized glutathione (GSSG) at 36 weeks PMA were measured and the redox potential was calculated using Nernst equation. Student's t-test, Chi-square, Spearman correlation, ANOVA, and logistic regression analyses were used as appropriate. P < 0.05 was considered significant. FiO2 ≥25% was associated with higher level of GSSG (0.29 ± 0.04 versus 0.18 ± 0.02 nmol/mg of protein), a more oxidized redox potential (-191 ± 2 versus -198 ± 2 mV) and more BPD (90% versus 45%). PN duration >14 days was also associated with higher level of GSSG (0.26 ± 0.03 versus 0.13 ± 0.02 nmol/mg of protein), a more oxidized redox potential (-193 ± 5 versus -203 ± 2 mV) and more BPD (89% versus 24%). In logistic regression model, each 1% increase in FiO2 and each day increase in PN duration resulted in an increase in the OR for BPD by 1.57 (1.09 -2.28) and 1.17 (1.03 -1.33) respectively. Early O2 supplement and PN have additive effects that were associated with prolonged oxidative stress and increased risk of BPD. Strategies targeting judicious use of O2 and decreasing the duration or developing a safer formulation of PN can be targeted to decrease BPD.

Feeding difficulties during the neonatal period

Feeding difficulties (FD) are a major issue in neonatology, as they could hamper the assessment of an adequate enteral nutrition, delay hospital discharge and lead to breastfeeding failure. Functional and anatomical maturation of the gastrointestinal tract is strictly related to gestational age (GA); hence, premature infants are more prone to develop FD. Feeding intolerance (FI) is very common among preterm infants; clinical symptoms of FI (e.g. abdominal distension, vomiting, bilious gastric residuals, occult or gross bloody stools) are observed in nearly 29% of such neonates [1]. FI could represent an early sign of necrotizing enterocolitis (NEC), which is the most feared gastrointestinal complication of prematurity. Hence, FI often brings clinicians to withhold, decrease or discontinue enteral feeds, thus hampering the establishment of an adequate enteral nutrition and leading to a prolonged duration of both parenteral nutrition (PN) and central lines, with increased risks of such complications as liver cholestasis or sepsis[2]. The coordination between sucking, swallowing and breathing is usually achieved at 34-36 weeks GA; hence, preterm infants are usually fed via an intragastric tube, through intermittent boluses or continuously. Poor sucking and sucking-swallowing incoordination are the major causes of FD and breastfeeding failure among late preterm infants (GA 34-366/7 weeks), with an increased risk of hypoglycemia, excessive weight loss, hyperbilirubinemia, dehydration[3]. Due to FD, up to 27% of all late preterm infants need to be initially supplemented with intravenous fluids[4]; moreover, tube feeding is frequently required for feeding administration in the first days of life. The abovementioned problems are infrequent in healthy term newborns. Term neonates developing FD such as poor sucking and/or vomiting need to be evaluated for pathological causes. Physical examination could aid to identify anatomical malformations possibly responsible for FD (e.g. cleft palate). FD and sleepiness can be due to hyperbilirubinemia, hypoglycemia or electrolyte disturbances[5], but could also subtend an underlying metabolic disease, such as hypothyroidism. FD, lethargy and/or other clinical neurological signs (e.g. seizures, focal neurological signs, hypo- or hypertonia, bulging fontanel, central apnoea) could address for central nervous system diseases (i.e. subarachnoid haemorrhage, ischaemic stroke, metabolic encephalopathy etc.). FD and lethargy could also represent a warning sign for invasive infections, especially if associated with respiratory distress, apnoea and bradycardia, temperature instability and increased capillary refill time[5]. Blood tests (including blood cells count, C-reactive protein, glucose, bilirubin, electrolytes, blood gas analysis) and cerebral ultrasound scan are useful tools to aid neonatologists in the differential diagnosis.

Parenteral nutrition associated cholestasis

Parenteral nutrition (PN) is life saving for many preterm infants and other neonates with severe illness, but prolonged use of PN can lead to intrahepatic cholestasis, referred to as parenteral nutrition–associated cholestasis (PNAC). It is defined as direct bilirubin greater than 2.0 mg/dL persistent for at least 2 consecutive tests duringthe administration of PN, not associated with other known causes of cholestasis [1-3]. With the increasing survival of preterm infants and neonates requiring intensive care, PNAC has become a more common clinical challenge. The incidence of PNAC varywidely depending on the population studied, with high incidencein populations carrying several risk factors for PNAC. It increases with duration of PN and ranges from 10% to 85% in infants [4-8]. A multifactorial aetiology has been proposed for the development of PNAC. Recognized risk factors for PNAC include low birth weight, low gestational age, necrotizing enterocolitis, intestinal malformations, and intestinal surgery. A further risk factor is the occurrence ofsevere infections, due to the requirement for central line for infusion of PN, and bacterial overgrowth caused by enteralstarvation and immature immune function[9-13]. However, exposure to PN is demonstratedas the main factor in the development of PNAC. Intravenous hyper-alimentationhas been implicated, such as thetotal caloric overload, the quality of aminoacid solutions, the cumulative amount and the quality of lipid infusion, the presence of excessivealuminium in the PN solution, and the high manganese intake with PN [1,14-17]. Ursodeoxycholic acid, cyclic PN, light protection for PN, tapering the soybean-based lipid emulsion, and antibiotics to decontaminate bacterial overgrowth are used to treat PNAC [18-21]. In recent years, increasing attention has been paid to the lipid content in PN. It has been found that fish oil–containing lipid emulsions could be useful in infants to reverse PNAC for whom enteral feeding is intolerable. However, no evidence supports the use of fish oil–containing lipid emulsions to prevent PNAC in neonates, including preterm infants [22]. Enteral feeding remains the best strategy to reverse and prevent PNAC, with as little as 10% of caloric intake showing beneficial effects [5,22].