Risk Of Growth Failure Research Articles

Body composition after implementation of an enhanced parenteral nutrition protocol in the neonatal intensive care unit: a randomised pilot trial

Background Very low birthweight (VLBW) infants are at risk for growth failure and poor neurodevelopment. Optimised parenteral nutrition may help promote optimal growth and development, but concerns that provision of enhanced nutrition may contribute to increased early adiposity and later metabolic disease remain. Aim To determine associations between provision of an early enhanced parenteral nutrition protocol or standard parenteral nutrition protocol and growth and body composition for VLBW preterm infants in the neonatal intensive care unit. Subjects This is a secondary analysis of data from a clinical trial aimed at assessing the feasibility and safety of randomising VLBW preterm infants to Standard (n = 45) or Intervention (n = 42) parenteral nutrition groups between August 2017 and June 2019. Methods We evaluated associations between weekly infant growth and body composition measurements from n = 55 infants (Standard = 29, Intervention = 26) that were clinically stable enough to have body composition measurements taken before discharge using mixed effects linear regression models. Result No statistically significant associations between nutrition group and infant growth or body composition measures were observed (p >.05). Conclusion In this pilot trial, enhanced parenteral nutrition in the first week of life was not associated with significant differences in infant growth or body composition during hospitalisation.

Nutritional Needs of the Infant with Bronchopulmonary Dysplasia.

Growth failure is a common problem in infants with established bronchopulmonary dysplasia (BPD). Suboptimal growth for infants with BPD is associated with unfavorable respiratory and neurodevelopmental outcomes; however, high-quality evidence to support best nutritional practices are limited for this vulnerable patient population. Consequently, there exists a wide variation in the provision of nutritional care and monitoring of growth for infants with BPD. Other neonatal populations at risk for growth failure, such as infants with congenital heart disease, have demonstrated improved growth outcomes with the creation and compliance of clinical protocols to guide nutritional management. Developing clinical protocols to guide nutritional management for infants with BPD may similarly improve long-term outcomes. Given the absence of high-quality trials to guide nutritional practice in infants with BPD, the best available evidence of systematic reviews and clinical recommendations can be applied to optimize growth and decrease variation in the care of these infants.

Exploring Growth Failure in Neonates With Enterostomy

Aim of the studyNeonatal enterostomy is a known risk for growth failure. We hypothesized that episodes of inflammation may drive a catabolic state, exploring this by assessing serum biochemistry alongside growth trajectory in enterostomy patients. MethodsA retrospective analysis of infants with histologically confirmed NEC from 01/2012–07/2021 in a tertiary neonatal surgical centre was performed. Change in weight-for-age Z-score (ΔZ) between stoma formation and closure was calculated. Serum CRP (C-reactive protein), urea, and creatinine levels were recorded and duration of elevated levels calculated as Area Under Curve (AUC). We examined for trends of serum levels rising together using intersecting moving averages. Spearman's correlation analysis was performed, while multivariable linear regression examined factors associated with ΔZ. Results79 neonates were included. At stoma formation, median Z-score was −1.42 [range −4.73, +1.3]. Sixty-two patients (78 %) had a fall in Z-score during their time with a stoma, 16 (20 %) had a ΔZ less than −2. Urea AUC was significantly univariably correlated with ΔZ and remained statistically significant in a multivariable model (Exp(B) x 100 = −0.57[−1, −0.09]; p = 0.022). The number of biomarker peaks correlated significantly with ΔZ for urea (r = −0.25; p = 0.025) and CRP (r = −0.35; p = 0.0017) but not Creatinine (r = −0.21; p = 0.066). Analysing the number of peaks of any combination of variables coinciding was consistently significantly correlated negatively with ΔZ (r = −0.29 to −0.27; p ≤ 0.016 for all). ConclusionOur data shows that infants who were more severely affected by growth failure had more frequent and severe uremia while they had a stoma (suggesting a catabolic state). Disturbances in urea were commonly associated with CRP, suggesting that inflammation is a significant factor in growth failure in these infants. These findings promote aggressive management of sepsis in these infants, as well as suggesting an earlier closure of stoma to minimise their “at-risk”’ period.

Low Sodium Supply in Early Life Causes Growth Restriction and Programs Long‐Term Changes in Energy Homeostasis

Preterm birth is a risk factor for the development of a multitude of diseases later in life. Preterm infants are also at risk for growth failure following parturition, which further compounds the adverse effects of preterm birth. Previous studies have shown that prematurely born human infants’ kidneys are inefficient at retaining sodium, therefore putting these infants at high risk of sodium depletion. We have developed a “post‐wean” dietary manipulation to model early‐life sodium depletion. In this model, mice are fed variations of soy‐free 2920x diet (Teklad); low‐sodium (0.04% Na, n=6), or high/normal‐sodium (0.30% Na, n=8), from weaning at week three of life, until week six of life. At six weeks of age, all mice are switched back to the “standard” 2920x diet (0.15% Na). Food and water intake behaviors, physical activity, energy expenditure, and body composition of the mice were serially analyzed using a multiplexed phenotyping system (Promethion, Sable Systems International) and time‐domain nuclear magnetic resonance (NMR; Bruker LF110). Mice supplied low‐Na between 3‐6 weeks of age exhibited delayed growth during weeks 3‐6, then rapid “catch‐up growth” following return to “normal” diet in week 6, and similar growth kinetics to the high‐Na group thereafter (diet x age interaction p<0.01). The delay in body mass expansion in the low‐Na group was due to a decrease in fat‐free mass (diet x age interaction p<0.01). Mice fed low‐Na diet exhibited reduced food intake (diet p<0.01), due to slower eating speed (diet p<0.01) and meal size (diet p=0.01). The reduced food intake relative to body composition was sustained through 18 weeks of age (diet x age interaction p=0.93). Water intake was also increased in mice treated with low‐Na diet both during diet intervention and through 18 weeks of age (diet p<0.01), due to an increased number of drinking bouts (diet p<0.01) of comparable size (diet p=0.46). Total aerobic energy expenditure was increased in mice fed the low‐Na diet, even after correction for body composition (diet p<0.01). Mice treated with low‐Na diet in early life also exhibited an increase in energy expenditure that was maintained through 18 weeks of age (diet x age p>0.99), even after correction for body composition and for differences in food intake. Finally, mice treated with low‐Na diet demonstrate a reduction in calories that are unaccounted for by these methods (diet p<0.01, diet x age interaction p=0.68). In conclusion, post‐wean sodium depletion causes growth failure and changes in body composition that parallel premature human infant growth failure. Profoundly, this relatively simple 3‐week diet switch causes changes in intake behaviors and energy expenditure that are then “programmed” for at least another 12 weeks after switch back to a “normal” diet. These findings support our working hypothesis that early‐life sodium supply impacts energy homeostasis and growth kinetics and prompts reconsideration of current guidelines concerning sodium supplementation to prematurely born and low‐birthweight infants.

Poor weight gain and its predictors among preterm neonates admitted at Muhimbili National Hospital in Dar-es-salaam, Tanzania: a prospective cohort study

BackgroundPreterm delivery is among the major public health problems worldwide and the leading cause of morbidity and mortality among neonates. Postnatal poor weight gain, which can contribute to mortality, can be influenced by feeding practices, medical complications and quality of care that is provided to these high-risk neonates. This study aimed to investigate the proportion and predictors of poor weight gain among preterm neonates at Muhimbili National Hospital (MNH), from September 2018 to February 2019.MethodsA hospital-based prospective cohort study involving preterm neonates with Gestation age (GA) < 37 weeks receiving care at MNH. Eligible preterm, were consecutively recruited at admission and followed up until discharge, death or end of neonatal period. Poor weight gain was defined as weight gain less than 15 g per kg per day. The risk factors associated with poor weight gain were evaluated. Predictors of poor weight gain were evaluated using a multivariate analysis. Results were considered statistically significant if P -value was < 0.05 and 95% confidence interval (CI) did not include 1.ResultsA total of 227 preterm neonates < 37 weeks GA, with male to female ratio of 1:1.2 were enrolled in the study. The overall proportion of preterm with poor weight gain was 197/227 (86.8%). Proportion of poor weight gain among the early and late preterm babies, were 100/113 (88.5%) and 97/114 (85.1%) respectively. Predictors of poor weight gain were low level of maternal education (AOR = 2.58; 95%Cl: 1.02–6.53), cup feeding as the initial method of feeding (AOR = 8.65; 95%Cl: 1.59–16.24) and delayed initiation of the first feed more than 48 h (AOR = 10.06; 95%Cl: 4.14–24.43). A previous history of preterm delivery was protective against poor weight gain (AOR = 0.33; 95% Cl: 0.11–0.79).Conclusion and recommendationPoor weight gain was a significant problem among preterm neonates receiving care at MNH. This can be addressed by emphasizing on early initiation of feed and tube feeding for neonates who are not able to breastfeed. Health education and counselling to mothers focusing on feeding practices as well as close supervision of feeding especially for mothers experiencing difficulties in feeding their preterm will potentially minimize risk of growth failure.

The effect of milk type and fortification on the growth of low-birthweight infants: An umbrella review of systematic reviews and meta-analyses.

Approximately 15% of infants worldwide are born with low birthweight (<2500 g). These children are at risk for growth failure. The aim of this umbrella review is to assess the relationship between infant milk type, fortification and growth in low‐birthweight infants, with particular focus on low‐ and lower middle–income countries. We conducted a systematic review in PubMed, CINAHL, Embase and Web of Science comparing infant milk options and growth, grading the strength of evidence based on standard umbrella review criteria. Twenty‐six systematic reviews qualified for inclusion. They predominantly focused on infants with very low birthweight (<1500 g) in high‐income countries. We found the strongest evidence for (1) the addition of energy and protein fortification to human milk (donor or mother's milk) leading to increased weight gain (mean difference [MD] 1.81 g/kg/day; 95% confidence interval [CI] 1.23, 2.40), linear growth (MD 0.18 cm/week; 95% CI 0.10, 0.26) and head growth (MD 0.08 cm/week; 95% CI 0.04, 0.12) and (2) formula compared with donor human milk leading to increased weight gain (MD 2.51 g/kg/day; 95% CI 1.93, 3.08), linear growth (MD 1.21 mm/week; 95% CI 0.77, 1.65) and head growth (MD 0.85 mm/week; 95% CI 0.47, 1.23). We also found evidence of improved growth when protein is added to both human milk and formula. Fat supplementation did not seem to affect growth. More research is needed for infants with birthweight 1500–2500 g in low‐ and lower middle–income countries.

Review of Preterm Human-Milk Nutrient Composition.

The human milk-fed preterm infant is at risk for growth failure, micronutrient deficiencies, and neurocognitive delay. Although protective and better tolerated than formula, human milk alone cannot meet the high nutrient requirements of this population, and fortification is necessary. Clinicians use assumptions of preterm human-milk composition to determine the type and quantity of fortification. The objectives of this review were to identify evidence of macronutrient and micronutrient concentration in preterm human milk and to identify knowledge gaps regarding composition. PubMed and the Cumulative Index to Nursing and Allied Health Literature were used to identify original articles published between January 1950 and December 2019. Twenty-seven articles were found containing original data on macronutrients and micronutrients. Most (67%) of the studies published after 2011 measured the macronutrients and included gestational ages from 28 to 36 weeks. Milk collection methods, experimental design, and analytical methods varied between studies. There are 15 countries represented in this review; all of the American studies (n = 7) were published from 1980 to 1984. African American women, or women delivering before 28 weeks' gestation are not represented in the literature. Accurate and targeted human-milk fortification depends on comprehensive, complete, and representative human-milk nutrient data. We have aggregated all available preterm human-milk macronutrient and micronutrient data and reported trends associated with lactation stage and gestational age. This report can aid in the design of feeding plans that are appropriate for the gestational age of the preterm infant and the lactation stage of the breastmilk.

Low prevalence of clinical decision support to calculate caloric and fluid intake for infants in the neonatal intensive care unit

BackgroundClinical decision support (CDS) improves nutrition delivery for infants in the neonatal intensive care unit (NICU), however, the prevalence of CDS to support nutrition is unknown.MethodsOnline surveys, with telephone and email validation of responses, were administered to NICU clinicians in the Children’s Hospital Neonatal Consortium (CHNC). We determined and compared the availability of CDS to calculate calories and fluid received in the prior 24 h, stratified by enteral and parenteral intake, using McNemar’s test.ResultsClinicians at all 34 CHNC hospitals responded with 98 of 108 (91%) surveys completed. NICUs have considerably less CDS to calculate enteral calories received than enteral fluid received (32% vs. 82%, p < 0.001) and less CDS to calculate parenteral calories received than parenteral fluid received (29% vs. 82%, p < 0.001).DiscussionMost CHNC NICUs are unable to reliably and consistently monitor caloric intake delivered to critically ill infants at risk for growth failure.

Resting energy expenditure in infants with congenital diaphragmatic hernia without respiratory support at time of neonatal hospital discharge

BackgroundInfants with congenital diaphragmatic hernia (CDH) are at risk for growth failure because of inadequate caloric intake and high catabolic stress. There is limited data on resting energy expenditure (REE) in infants with CDH. AimsTo assess REE via indirect calorimetry (IC) in term infants with CDH who are no longer on respiratory support and nearing hospital discharge with advancing post-conceptional age and to assess measured-to-predicted REE using predictive equations. MethodsA prospective cohort study of term infants with CDH who were no longer on respiratory support and nearing hospital discharge was conducted to assess REE via IC and caloric intake. Baseline characteristics and hospital course data were collected. Three day average caloric intake around time of IC testing was calculated. Change in REE with advancing post-conceptional age and advancing post-natal age was assessed. The average measured-to-predicted REE was calculated for the cohort using predictive equations [22]. ResultsEighteen infants with CDH underwent IC. REE in infants with CDH increased with advancing postconceptional age (r2 = 0.3, p < 0.02). The mean REE for the entire group was 53.2 +/− 10.9 kcal/kg/day while the mean caloric intake was 101.2 +/− 17.4 kcal/kg/day. The mean measured-to-predicted ratio for the cohort was in the normal metabolic range (1.10 +/− 0.17) with 50% of infants considered hypermetabolic and 11% of infants considered hypo-metabolic. ConclusionsInfant survivors of CDH repair who are without respiratory support at time of neonatal hospital discharge have REE, as measured by indirect calorimetry, that increases with advancing post-conceptional age and that is within the normal metabolic range when compared to predictive equations. Level of EvidenceIII

Advances in the catch-up growth of preterm infants

How to promote premature to achieve more appropriate catch-up growth is the focus issue of neonatal and pediatric primary care research.Growth restriction can increase the risks of growth failure, including physical growth and nervous system development.Excessive catch-up growth is responsible for cardiovascular(hypertension, microvasculopathy), metabolic morbidities(insulin resistance, liver steatosis)in adult even adolescent life.In this paper, the research progress of the growth evaluation, influencing factors and excessive growth in the catch-up growth of preterm infants is reviewed. Key words: Premature; Catch-up growth; Evaluation

Longitudinal Growth in Children and Adolescents with Type 1 Diabetes.

To study longitudinal growth in children with type 1 diabetes mellitus. Anthropometry, disease duration, insulin regimens and HbA1C recorded from patients with diabetes enrolled in a specialty clinic. 160 children (75 boys; mean (SD) age 9.4 (3.3) y) were enrolled. 35% children had low (<25th centile) height velocity. Disease duration and HbA1C affected height velocity (adjusted for puberty). Children on basal-bolus had higher height velocity Z scores than those on a split mix regimen [(0.5(1.6) vs. -0.3(1.4), P<0.05)]. Children diagnosed before 5 years of age had lowest height velocity. Of the children who reached final height, 53% remained below target height. Children with type 1 diabetes mellitus have lower height velocity compared to healthy children; those diagnosed at younger age were at higher risk for growth failure.

Comparison of Feeding Strategies for Infants With Hypoplastic Left Heart Syndrome: A Randomized Controlled Trial.

Infants with hypoplastic left heart syndrome are at risk for growth failure, particularly after stage 1 procedures. The effect of continuous enteral feedings on weight gain has not been previously investigated. A randomized controlled trial was performed in infants with hypoplastic left heart syndrome and single ventricle variants after stage 1 procedures. Eligible infants were randomized to a continuous and intermittent feeding regimen or an exclusive intermittent feeding regimen after stage 1 procedures and continued until hospital discharge. Anthropometric measures and markers of nutritional status were assessed throughout hospitalization. Twenty-six infants completed the study. There were no significant differences in weight gain, growth, or nutritional status. Weight gain on full enteral feedings was 24.3 versus 23.6 g/d (P = .88) for the combination (continuous and intermittent) versus intermittent feeding groups. Weight-for-age Z scores at discharge were -1.37 versus -1.2 (P = .59) for the combination versus intermittent groups. No significant differences in weight gain, growth, or nutritional status were observed at hospital discharge between the two feeding strategies. Despite both groups achieving target daily weight gain after attaining full feeds, growth failure continued to be a problem after stage 1 procedures. Further strategies to improve growth during initial hospitalization are needed.

Poor post-operative growth in infants with two-ventricle physiology

Adequate nutritional support is essential for normal infant growth and development. Infants with congenital cardiac disease are known to be at risk for growth failure. We sought to describe perioperative growth in infants undergoing surgical repair of two-ventricle congenital cardiac disease and assess for predictors of their pattern of growth.Materials and methodsFull-term infants who underwent surgical repair of two-ventricle congenital cardiac disease at a single institution were enrolled in a retrospective cohort study performed following a larger prospective study. Infants with facial, gastrointestinal, or neurologic anomalies, trisomy chromosomal abnormality, birth weight less than 2500 grams, or those transferred to another institution before discharge home were excluded. The primary outcome was change in weight-for-age z score from surgery to discharge. Our secondary outcome variable was post-operative hospital length of stay. A total of 76 infants met the inclusion criteria. Medain age at surgery was 5 days with a range from 1 to 44. The median weight-for-age z score at surgery was -0.2 with a range from -2.9 to 2.8 and by discharge had dropped to -1.2 with a range from -3.4 to 1.8. The median change in weight-for-age z score from surgery to discharge was -1.0 with a range from -2.3 to 0.2. Delayed post-operative nutrition (p < 0.001) and reintubation following initial post-operative extubation (p = 0.001) were associated with decrease in weight-for-age z score. Infants undergoing repair of two-ventricle congenital cardiac disease had poor growth in the post-operative period. This may be mitigated by early initiation of post-operative nutrition.

Predictors of Poor Weight Gain in Infants with a Single Ventricle

To assess growth from the time of neonatal discharge to the time of performance of the bidirectional Glenn (BDG) procedure in infants with a single ventricle and determine predictors of poor growth. We performed a retrospective case series of infants who underwent the BDG procedure at our institution between January 2001 and December 2007 (n=102). Anthropometric and clinical data were recorded during neonatal hospitalization and before BDG. Outcome variables included weight-for-age z-score (WAZ) at the time of BDG and average daily weight gain between neonatal discharge and BDG. Median age at the time of BDG was 5.1 months (range, 2.4-10 months), and median WAZ was -0.4 (range, -2.6 to 3.2) at neonatal admission and -1.3 (range, -3.9 to 0.6) at the time of BDG. Non-Caucasian infants (P=.03) and those with lower WAZ at neonatal discharge (P<.0001) had a lower WAZ at BDG. Being formula-fed at neonatal discharge (P=.04), and having higher mean pulmonary arterial pressure (P=.04) and systemic oxygen saturation (P=.006) were associated with lower average daily weight gain between neonatal discharge and BDG. Infants with a single ventricle have poor weight gain between neonatal discharge and BDG. Non-Caucasian infants and those with evidence of increased pulmonary blood flow are at particular risk for growth failure.

Iron Overload and Iron Chelation Therapy in Pediatric Patients

Iron overload is an unfortunate clinical consequence of repeated blood transfusions that can cause significant organ damage, morbidity, and mortality in the absence of proper treatment. Pediatric patients with transfusion-dependent pathologies face the additional risk of growth failure and poor sexual development owing to iron build-up in the anterior pituitary gland. Iron chelation therapy is necessary for the removal of excess iron, but treatment efficacy and success are highly dependent on patient compliance. Deferoxamine is a well-established but inconvenient therapy requiring parenteral administration over extended periods of time. Patient compliance can be improved with use of the oral iron chelators deferasirox and deferiprone. Long-term data have shown deferasirox to have a good safety and efficacy profile in pediatric patients.

Post‐discharge nutrition for the preterm infant

Newly designed, 'enriched,' formulas are now available for the formula feeding premature infant after hospital discharge. These new formulations add to the array of milks from which to choose when the discharge of the premature infant is approaching. However, the data to support optimal or reference nutrient intakes to use for the premature infant in the post-discharge are lacking. Breastfeeding should be encouraged as its beneficial effects may be related to the duration in which it is fed. Infants at risk for growth failure in the post-discharge period, such as infants unable to consume ad libitum intakes of milk, and who already have growth faltering or abnormal nutritional indices, may benefit for the addition of enriched formula. This review summarizes the recent data and comments on recommendations on post-discharge nutrition for premature infants.

Feeding Management of Infants with Cleft Lip and Palate and Micrognathia

The baby with a cleft lip, palate, and/or micrognathia presents a feeding challenge for both parents and health professionals. These oral-facial anomalies may disaipt the feeding process and put the baby at risk for growth failure and sometimes aspiration. The feeding difficulties of these babies are widely reported in the literature, but no consensus on how to select the most appropriate remediation techniques is evident. This article outlines the components of the normal infant feeding process and how they are affected by these oral-facial anomalies. Based on the child's specific pattern of anomalies, this article discusses a variety of feeding techniques and management strategies and develops a rationale for their use in bottle and breastfeeding of infants with cleft lip, palate, and/or micrognathia.

GROWTH IN INFANTS WITH BRONCHOPULMONARY DYSPLASIA AFTER INITIAL HOSPITAL DISCHARGE. 1595

Bronchopulmonary Dysplasia (BPD) is often associated with long term growth problems. This study was designed to examine current rates of growth failure in infants with BPD and to prospectively determine risk factors associated with growth failure. After initial hospital discharge, the growth of 40 infants with mean gestational age of 27 ± 2 weeks, was followed with 7 monthly home visits. Potential risk factors included, low energy intake, feeding problems, difficult temperament, low socioeconomic status (SES), post discharge illness/hospitalization, and compromised caregiver-infant feeding relationship. Z score differences were calculated between the first visit and the last visit. Twenty nine infants (73%) experienced a drop in weight for age Z score, and 8 infants (20%) experienced a drop in height for age Z score. Risk of growth failure, defined as weight or length less than the 5th percentile at the last visit and experienced by 18 (45%) infants, was increased by low socioeconomic status (RR 2.13, 95% CI 1.04,4.33), significant feeding difficulties (RR 2.33, 95% CI 1.24,4.38), and difficult temperament(RR 2.08, 95% CI 1.04,4.19). Problems associated with feeding were common and included choking, coughing, cyanosis, crying, and fatigue. Infants with growth failure were more likely to have a “suspect” finding on the Denver II (Chi square 6.05, p=0.014). Growth failure and feeding problems continue to be a problem for infants with BPD. We found that growth was adversely affected by low socioeconomic status, feeding difficulties, and difficult temperament. High risk infants may benefit from frequent nutrition assessment and intervention for feeding problems.

THE DIETARY RECOMMENDATIONS OF THE AMERICAN ACADEMY OF PEDIATRICS

The AAP cannot logically embrace two contradictory positions put forward by their 1992 Committee on Nutrition: 1) recommending 30% of energy from fat but 2) not one percentile less. Although a population nutrient goal of 30% of energy from fat is reasonable for adults, because ingestion of this amount of energy from fat will not jeopardize their growth, this guideline developed from studies of adults (mostly males) does not and should not apply to children. Because this goal was recommended for children by the 1992 Committee on Nutrition it is obvious that, if implemented, some children will be at risk for growth failure. The pediatricians in Canada have solved this problem by recommending a tapering decrease of fat intake from 50% of energy from fat at age 2 years to 30% by the time of the conclusion of linear growth (ie, adolescence) (11).

Protein Restriction in Children with Chronic Renal Failure?

Normal growth can be obtained in infants with congenital renal disease and advanced chronic renal failure by feeding age-corrected amounts of protein and calories. Malnutrition during the first 2 years of life leads to stunting which cannot be corrected later in life. Chronic administration of extra calories has not resulted in catch-up growth. The potential benefit of protein restriction for prevention of renal function has to be balanced against the risk of growth failure in children with chronic renal failure. The problem can only be solved by prospective controlled studies in different age groups.