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Optimizing Nutritional Content of Enteral Nutrition For Preterm Infants PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Optimizing nutritional content of enteral nutrition for preterm infants" by Roger F. Soll, MD.

This medical PowerPoint presentation tells us why optimizing the nutritional content of enteral nutrition for preterm infants is critical for their growth and development. Enteral nutrition refers to the provision of nutrition through the gastrointestinal tract, and is typically given to preterm infants who are unable to take sufficient amounts of nutrition by mouth.

The nutritional needs of preterm infants are different from those of full-term infants and adults. Preterm infants require higher amounts of protein, calories, and micronutrients to support their growth and development. The nutritional content of enteral nutrition for preterm infants should be carefully balanced to ensure that they receive adequate amounts of all essential nutrients.

Tags : enteral nutrition for preterm infants, provision of nutrition through the gastrointestinal tract, preterm infants, Pediatrics, Pediatrics PowerPoint presentation

Published on : Jun 23, 2023 | Views : 1700 | Downloads : 1

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Slide 1-

Evidence in practice:Optimizing nutritional content of enteral nutrition for preterm infants Roger F. Soll, MD H. Wallace Professor of Neonatology Larner College of Medicine, University of Vermont Coordinating Editor, Cochrane Neonatal President, Vermont Oxford Network 1
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Editorial Team Roger F. Soll Coordinating Editor Colleen Ovelman Managing Editor Clare LaFrance Program Coordinator Bill McGuire Coordinating Editor
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Jeffrey Horbar University of Vermont Prakeshkumar Shah University of Toronto K. Suresh Gautham Baylor College of Medicine Editorial Team Jackie Ho RCSI & UCD Malaysia Campus David Osborn University of Sydney
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Associate Editors
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Guest Discussants Brenda Poindexter, MD, MS Professor, Emory University School of Medicine Chief of Neonatology, Children’s Healthcare of Atlanta Bill McGuire Professor, Hull York Medical School Coordinating Editor Cochrane Neonatal
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Sponsors Section on Neonatal-Perinatal Medicine
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Sponsors Cochrane Neonatal received unrestricted grant support to update reviews on feeding preterm infants from the Gerber Foundation
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Disclosure Roger F. Soll, M.D. is the Vice President of the Vermont Oxford Network and the Coordinating Editor of Cochrane Neonatal No other relevant financial issues to disclose Optimizing nutritional content: Evidence from Cochrane systematic reviews
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To develop an understanding of the strengths and weaknesses of evidence provided by systematic reviews and meta-analyses to inform our practice of neonatal-perinatal medicine. Today’s focus will be on optimizing nutrition through supplementation and fortification. Optimizing nutritional content: Evidence from Cochrane systematic reviews
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Strategies for Feeding the Preterm Infant William W. Hay, Jr. Neonatology. 2008; 94(4): 245–254. Published online 2008 Oct 2. doi: 10.1159/000151643
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As a greater number of smaller and smaller preterm infants survive, caregivers have been called on to develop more effective nutritional strategies, including optimizing breast feeding and developing newer formulas, supplements to enteral feeds, and parenteral feeding solutions. Optimizing nutritional content: Evidence from Cochrane systematic reviews
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American Academy of Pediatrics Committee on Nutrition: Nutritional needs of low-birth-weight infants. Pediatrics. 1985;76:976–986. Goal of Nutrition for Preterm Infants Most neonatologists have accepted the recommendation of the American Academy of Pediatrics that growth of the postnatal preterm infant, both their anthropometric indices and body composition, should be the same as the normal fetus of the same gestational age growing in its mother’s uterus. In reality, this proves to be a challenge……
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Reports from NICUs across the world demonstrate that we have considerable room for improvement. The growth of nearly all preterm infants during their hospitalization in intensive care, especially those at the earliest gestational ages, lag far behind fetal growth curves in the third trimester. In the Vermont Oxford Network database, 31% of VLBW infants have extreme growth failure, defined as being less than the 3rd percentile on the Fenton Growth Chart at discharge. However, this failure in sustaining adequate growth varies greatly between centers (1st quartile 20%, 3rd quartile 40%). Optimizing nutritional content: Evidence from Cochrane systematic reviews
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Variation in practice A great deal of variation is seen in feeding practices worldwide. (Klingenberg and colleagues. Arch Dis Child 2012). For example, 69% of units in the UK and Ireland routinely use human milk fortifier, whereas 100% of units in Canada report routine use. Optimizing nutritional content: Evidence from Cochrane systematic reviews
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What are the downstream effects of undernutrition and growth failure? Numerous studies have shown that failure to meet the preterm infant’s nutritional goals at critical stages of development produces serious problems for the preterm infant, including: short stature, growth failure, abnormalities of brain growth and development. Optimizing nutritional content: Evidence from Cochrane systematic reviews
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What are the current gaps in caregiver knowledge and practice regarding early enteral nutrition for preterm infants? We have identified three key areas of gaps in preterm infant nutrition knowledge and practice for the proposed project: (1) types of feeding, (2) optimizing nutritional content of feeds, and (3) feeding strategies and methods. Optimizing nutritional content: Evidence from Cochrane systematic reviews
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So…. What do we know from trials?
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The facts Ma’am… just the facts.
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Protein supplementation Lipid supplementation Multi-nutrient fortification Timing of fortification Individualized fortification Optimizing nutritional content: Evidence from Cochrane systematic reviews
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Optimizing nutritional content: Evidence from Cochrane systematic reviews
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Comparison of different protein concentrations of human milk fortifier for promoting growth and neurological development in preterm infants Gao C, Miller J, Collins CT, Rumbold AR. Cochrane Database of Systematic Reviews 2020, in press. Art. No.: CD007090. DOI: 10.1002/14651858.CD007090. Optimizing nutritional content: Evidence from Cochrane systematic reviews
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Comparison of different protein concentrations of human milk fortifier Gao and colleagues. Cochrane Database of Systematic Reviews 2020, in press. Art. No.: CD007090. DOI: 10.1002/14651858.CD007090. Background: Human milk alone may provide inadequate amounts of protein to meet the growth requirements of preterm infants because of restrictions in the amount of fluid they can tolerate. It has become common practice to feed preterm infants with breast milk fortified with protein and other nutrients but there is debate about the optimal concentration of protein in commercially available fortifiers. Objectives: To compare the effects of different protein concentrations in human milk fortifier, fed to preterm infants, on growth and neurodevelopment. Selection criteria: We included all published and unpublished randomized, quasi-randomized and cluster-randomized trials comparing two different concentrations of protein in human milk fortifier. We included preterm infants (less than 37 weeks' gestational age). Participants may have been exclusively fed human milk or have been supplemented with formula. The concentration of protein was classified as low (< 1g protein/100 mL expressed breast milk (EBM)), moderate (≥ 1g to < 1.4g protein/100 mL EBM) or high (≥ 1.4g protein/100 mL EBM). We excluded trials that compared two protein concentrations that fell within the same category.
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Nine trials involving 861 infants. Gao and colleagues. Cochrane Database of Systematic Reviews 2020, in press. Art. No.: CD007090. DOI: 10.1002/14651858.CD007090. Comparison of different protein concentrations of human milk fortifier
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Comparison of different protein concentrations of human milk fortifier Gao and colleagues. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD007090. DOI: 10.1002/14651858.CD007090. Main results: We identified nine trials involving 861 infants (and nine ongoing trials!) The trials were mostly conducted in infants born < 32 weeks' gestational age or < 1500 g birth weight All used a fortifier derived from bovine milk. Two trials fed infants exclusively with mother's own milk, three trials gave supplementary feeds with donor human milk and four trials supplemented with preterm infant formula. Overall, trials were small but generally at low or unclear risk of bias.
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Comparison of different protein concentrations of human milk fortifier
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Comparison of different protein concentrations of human milk fortifier Gao and colleagues. Cochrane Database of Systematic Reviews 2020, in press. Art. No.: CD007090. DOI: 10.1002/14651858.CD007090. Authors' conclusions Feeding preterm infants with a human milk fortifier containing high amounts of protein (≥ 1.4g/100 mL EBM) compared with a fortifier containing moderate protein concentration (≥ 1 g to < 1.4 g/100 mL EBM) results in small increases in weight gain during the neonatal admission. There may also be small increases in weight and length gain when infants are fed a fortifier containing moderate versus low protein concentration (< 1 g protein/100 mL EBM). The certainty of this evidence is very low to moderate; therefore, results may change when the findings of ongoing studies are available. There is insufficient evidence to assess the impact of protein concentration on adverse effects or long term outcomes such as neurodevelopment. Further trials are needed to determine whether modest increases in weight gain observed with higher protein concentration fortifiers are associated with benefits or harms to long term growth and neurodevelopment.
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Higher versus lower protein intake in formula-fed low birth weight infants. Fenton TR, Al-Wassia H, Premji SS, Sauve RS. Cochrane Database of Systematic Reviews 2020, Issue 6. Art. No.: CD003959. DOI: 10.1002/14651858.CD003959.pub4. Optimizing nutritional content: Evidence from Cochrane systematic reviews
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Higher versus lower protein intake in formula-fed low birth weight infants Fenton and colleagues. Cochrane Database of Systematic Reviews 2020, Issue 6. Art. No.: CD003959. DOI: 10.1002/14651858.CD003959.pub4. Background: The ideal quantity of dietary protein for formula-fed low birth weight infants is still a matter of debate. Protein intake must be sufficient to achieve normal growth without leading to negative effects such as acidosis, uremia, and elevated levels of circulating amino acids. Objectives: To determine whether higher (≥ 3.0 g/kg/d) versus lower (< 3.0 g/kg/d) protein intake during the initial hospital stay of formula-fed preterm infants or low birth weight infants (< 2.5 kilograms) results in improved growth and neurodevelopmental outcomes without evidence of short- or long-term morbidity. Specific objectives were to examine the following comparisons of interventions: 1. Low protein intake if the amount was less than 3.0 g/kg/d. 2. High protein intake if the amount was equal to or greater than 3.0 g/kg/d but less than 4.0 g/kg/d. 3. Very high protein intake if the amount was equal to or greater than 4.0 g/kg/d.
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Six trials involving 218 infants. Fenton and colleagues. Cochrane Database of Systematic Reviews 2020, Issue 6. Art. No.: CD003959. DOI: 10.1002/14651858.CD003959.pub4. Higher versus lower protein intake in formula-fed low birth weight infants
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Higher versus lower protein intake in formula-fed low birth weight infants Fenton and colleagues. Cochrane Database of Systematic Reviews 2020, Issue 6. Art. No.: CD003959. DOI: 10.1002/14651858.CD003959.pub4. Main results: We identified six eligible trials that enrolled 218 infants. Five studies compared low (< 3 g/kg/d) versus high (3.0 to 4.0 g/kg/d) protein intake using formulas that kept other nutrients constant. The trials were small (n = 139), and almost all had methodological limitations; the most frequent uncertainty was about attrition. One study compared high (3.0 to 4.0 g/kg/d) versus very high (≥ 4 g/kg/d) protein intake (average intakes were 3.6 and 4.1 g/kg/d) during and after an initial hospital stay (n = 77).
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Higher versus lower protein intake in formula-fed low birth weight infants
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Higher versus lower protein intake in formula-fed low birth weight infants Fenton and colleagues. Cochrane Database of Systematic Reviews 2020, Issue 6. Art. No.: CD003959. DOI: 10.1002/14651858.CD003959.pub4. Authors' conclusions Higher protein intake (≥ 3.0 g/kg/d but < 4.0 g/kg/d) from formula accelerates weight gain. However, limited information is available regarding the impact of higher formula protein intake on long-term outcomes such as neurodevelopment. Research is needed to investigate the safety and effectiveness of protein intake ≥ 4.0 g/kg/d.
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Optimizing nutritional content: Evidence from Cochrane systematic reviews
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High versus low medium chain triglyceride content of formula for promoting short-term growth of preterm infants Perretta L, Ouldibbat L, Hagadorn JI, Brumberg HL. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD002777. DOI: 10.1002/14651858.CD002777. Optimizing nutritional content: Evidence from Cochrane systematic reviews
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High versus low medium chain triglyceride content of formula for promoting short-term growth of preterm infants Perretta and colleagues. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD002777. DOI: 10.1002/14651858.CD002777. Background: In-hospital growth of preterm infants remains a challenge in clinical practice. The high nutrient demands of preterm infants often leads to growth faltering. To improve growth, fat may be added to preterm formula in the form of medium chain triglycerides (MCT) or long chain triglycerides (LCT). MCT are easily accessible to the preterm infant with an immature digestive system, while LCT are beneficial for central nervous system development and visual function. Both have been incorporated into preterm formulas in varying amounts, but their effect on the preterm infant's short-term growth is unclear.
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High versus low medium chain triglyceride content of formula for promoting short-term growth of preterm infants Perretta and colleagues. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD002777. DOI: 10.1002/14651858.CD002777. Objectives: To determine the effect of formula containing high as opposed to low MCT on early growth in preterm infants fed a diet of primarily formula. Selection criteria: We included all randomized and quasi-randomized trials comparing the effects of feeding high versus low MCT formula (for a minimum of five days) on the short-term growth of preterm (< 37 weeks' gestation) infants. We defined high MCT formula as 30% or more by weight, and low MCT formula as less than 30% by weight. The infants must be on full enteral diets and the allocated formula must be the predominant source of nutrition.
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Ten trials involving 253 infants. Perretta and colleagues. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD002777. DOI: 10.1002/14651858.CD002777. High versus low medium chain triglyceride content of formula for promoting short-term growth of preterm infants
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High versus low medium chain triglyceride content of formula for promoting short-term growth of preterm infants Perretta and colleagues. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD002777. DOI: 10.1002/14651858.CD002777. The meta-analysis of weight gain velocity (g/kg/d) yielded a non-significant MD -0.21 (95% CI -1.24 to 0.83); 6 studies; 118 infants; low-certainty evidence. The analysis for weight gain (g/d) yielded a MD of 0.00 (-5.93 to 5.93) with one study (18 patients; moderate-certainty evidence) showing average weight gain of 20 ± 5.9 versus 20 ± 6.9 g/day for the high and low MCT groups, respectively.
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High versus low medium chain triglyceride content of formula for promoting short-term growth of preterm infants Perretta and colleagues. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD002777. DOI: 10.1002/14651858.CD002777. Length gain showed a non-significant MD of 0.10 cm/wk (95% CI -0.09 to 0.29; 3 studies; 61 infants; low-certainty evidence. Head circumference gain showed a non-significant MD of -0.04 cm/wk (95% CI -0.17, 0.09; 3 studies, 61 participants; moderate-certainty evidence). Subgroup analyses according to % MCT in the high MCT formula, by 10% intervals showed no evidence of effect of high MCT on short-term weight gain within any subgroup.
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High versus low medium chain triglyceride content of formula for promoting short-term growth of preterm infants Perretta and colleagues. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD002777. DOI: 10.1002/14651858.CD002777. Authors' conclusions There is no evidence of difference between MCT and LCT on short-term growth. Therefore, neither formula type could be concluded to improve short-term growth or have less adverse effects. Further studies are necessary because the results from the included studies are imprecise due to small numbers and do not address important long-term outcomes. Additional research should aim to clarify effects on formula tolerance and on long-term growth and neurodevelopmental outcomes, and include larger study populations to better evaluate effect on NEC incidence.
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Long chain polyunsaturated fatty acid supplementation in preterm infants. Dorling J, Simmer K, McClure J, Fieldhouse E, Ledwidge J. Cochrane Database of Systematic Reviews 2020, in process. Art. No.: CD000375. DOI: 10.1002/14651858.CD000375.pub5. Optimizing nutritional content: Evidence from Cochrane systematic reviews
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Long chain polyunsaturated fatty acid supplementation in preterm infants Dorling and colleagues. Cochrane Database of Systematic Reviews 2020, in process. Art. No.: CD000375. DOI: 10.1002/14651858.CD000375.pub5. Long chain polyunsaturated fatty acids (LCPUFA) may be essential nutrients for preterm infants because they may not be able to synthesize sufficient amounts of LCPUFA to meet the needs of the developing brain and retina. Objectives: To assess the safety and of benefits of formula milk supplemented with LCPUFA is to preterm infants. The effects of supplementation on the visual function, development and growth of preterm infants were particular areas of interest. Selection criteria: All randomized trials in enterally-fed preterm infants evaluating the effect of LCPUFA-supplemented formula compared with standard formula on visual development, neurodevelopment and physical growth. Trials reporting only biochemical outcomes were excluded.
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17 trials involving 2260 infants. Dorling and colleagues. Cochrane Database of Systematic Reviews 2020, in process. Art. No.: CD000375. DOI: 10.1002/14651858.CD000375.pub5. Long chain polyunsaturated fatty acid supplementation in preterm infants
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Long chain polyunsaturated fatty acid supplementation in preterm infants Dorling and colleagues. Cochrane Database of Systematic Reviews 2020, in process. Art. No.: CD000375. DOI: 10.1002/14651858.CD000375.pub5. Physical growth : Meta-analysis of five studies (N = 297) showed increased weight and length at two months post-term in supplemented infants Weight: MD 0.21, 95% CI 0.08 to 0.33; P = 0.0010; I² = 69% Length: MD 0.47, 95% CI 0.00 to 0.94; P = 0.05; I² = 0%
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Long chain polyunsaturated fatty acid supplementation in preterm infants Dorling and colleagues. Cochrane Database of Systematic Reviews 2020, in process. Art. No.: CD000375. DOI: 10.1002/14651858.CD000375.pub5. Physical growth Meta-analysis of four studies at a corrected age of 12 months (N = 271) showed no significant effect of supplementation on growth outcomes Weight: MD −0.10, 95% CI −0.31 to 0.12 Length: MD 0.25; 95% CI −0.33 to 0.84 Head circumference: MD −0.15, 95% CI −0.53 to 0.23. No significant effect of LCPUFA on weight, length or head circumference was observed on meta-analysis of two studies (n = 396 infants) at 18 months Weight: MD −0.14, 95% CI −0.39 to 0.10 Length: MD −0.28, 95% CI −0.91 to 0.35 Head circumference: MD −0.18, 95% CI −0.53 to 0.18 GRADE analysis for this outcome indicated that the overall quality of evidence was low for growth outcomes.
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Long chain polyunsaturated fatty acid supplementation in preterm infants Dorling and colleagues. Cochrane Database of Systematic Reviews 2020, in process. Art. No.: CD000375. DOI: 10.1002/14651858.CD000375.pub5. Visual acuity Visual acuity in the first year was measured by Teller or Lea acuity cards in eight studies, visual evoked potential (VEP) in six studies and by electroretinogram (ERG) in two studies. Most studies found no significant differences in visual acuity between supplementation or control treatments. The format of data presentation and the varying assessment methods precluded the use of meta-analysis. GRADE analysis indicated that the overall quality of evidence was low for visual acuity.
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Long chain polyunsaturated fatty acid supplementation in preterm infants Dorling and colleagues. Cochrane Database of Systematic Reviews 2020, in process. Art. No.: CD000375. DOI: 10.1002/14651858.CD000375.pub5. Neurodevelopment Three of seven studies reported some benefit of LCPUFA on neurodevelopment at different postnatal ages. Meta-analysis of four studies evaluating Bayley Scales of Infant Development at 12 months (N = 364) showed no significant effect of supplementation (Mental Development Index (MDI): MD 0.96, 95% CI −1.42 to 3.34; P = 0.43; I² = 71% Psychomotor Development Index (PDI): MD 0.23, 95% CI −2.77 to 3.22; P = 0.88; I² = 81%).
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Long chain polyunsaturated fatty acid supplementation in preterm infants Dorling and colleagues. Cochrane Database of Systematic Reviews 2020, in process. Art. No.: CD000375. DOI: 10.1002/14651858.CD000375.pub5. Authors' conclusions Infants enrolled in the trials were relatively mature and healthy preterm infants. Assessment schedule and methodology, dose and source of supplementation and fatty acid composition of the control formula varied between trials. On pooling of results, no clear long-term benefits or harms were demonstrated for preterm infants receiving LCPUFA-supplemented formula. Editor’s note: newer studies have reported on other clinical outcomes, including BPD, not discussed in the current review
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Optimizing nutritional content: Evidence from Cochrane systematic reviews
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Multi-nutrient fortification of human milk for preterm infants Brown JVE, Lin L, Embleton ND, Harding JE, McGuire W. Cochrane Database of Systematic Reviews 2020, Issue 6. Art. No.: CD000343. DOI: 10.1002/14651858.CD000343.pub4. Optimizing nutritional content: Evidence from Cochrane systematic reviews
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Multi-nutrient fortification of human milk for preterm infants Brown and colleagues. Cochrane Database of Systematic Reviews 2020, Issue 6. Art. No.: CD000343. DOI: 10.1002/14651858.CD000343.pub4. Human breast milk-fed preterm infants can accumulate nutrient deficits leading to extrauterine growth restriction. Feeding preterm infants with multi-nutrient fortified human milk could increase nutrient accretion and growth rates and improve neurodevelopmental outcomes. Concern exists, however, that multi-nutrient fortifiers are associated with adverse events such as feed intolerance and necrotizing enterocolitis. Objectives: To determine whether multi-nutrient fortified human milk, compared with unfortified human milk, affects important outcomes (including growth rate and neurodevelopment) of preterm infants without increasing the risk of adverse effects (such as feed intolerance and necrotizing enterocolitis). Selection criteria: Randomized and quasi-randomized controlled trials that compared feeding preterm infants with multi-nutrient (protein and energy plus minerals, vitamins, or other nutrients) fortified human breast milk versus unfortified (no added protein or energy) breast milk.
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18 trials involving 1456 infants. Brown and colleagues. Cochrane Database of Systematic Reviews 2020, Issue 6. Art. No.: CD000343. DOI: 10.1002/14651858.CD000343.pub4. Multi-nutrient fortification of human milk for preterm infants
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Brown and colleagues. Cochrane Database of Systematic Reviews 2020, Issue 6. Art. No.: CD000343. DOI: 10.1002/14651858.CD000343.pub4. Meta-analyses provided low- to moderate-certainty evidence showing that multi-nutrient fortification of human milk increases in-hospital rate of weight gain (MD 1.76 g/kg/d, 95% confidence interval (CI) 1.30 to 2.22) Multi-nutrient fortification of human milk for preterm infants in-hospital rate of weight gain (all trials)
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Multi-nutrient fortification of human milk for preterm infants in-hospital rate of weight gain (subgroup analysis) Brown and colleagues. Cochrane Database of Systematic Reviews 2020, Issue 6. Art. No.: CD000343. DOI: 10.1002/14651858.CD000343.pub4.
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Multi-nutrient fortification of human milk for preterm infants in-hospital rate of body length (cm/week)(all trials) Brown and colleagues. Cochrane Database of Systematic Reviews 2020, Issue 6. Art. No.: CD000343. DOI: 10.1002/14651858.CD000343.pub4. Meta-analyses provided low- to moderate-certainty evidence showing that multi-nutrient fortification of human milk increases in-hospital rate of body length (MD 0.11 cm/week, 95% CI 0.08 to 0.15)
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Brown and colleagues. Cochrane Database of Systematic Reviews 2020, Issue 6. Art. No.: CD000343. DOI: 10.1002/14651858.CD000343.pub4. Meta-analyses provided low- to moderate-certainty evidence showing that multi-nutrient fortification of human milk increases in-hospital rate of head circumference (MD 0.06 cm/week, 95% CI 0.03 to 0.08) Multi-nutrient fortification of human milk for preterm infants in-hospital rate of head circumference (cm/week) (all trials)
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Multi-nutrient fortification of human milk for preterm infants: Necrotizing Enterocolitis Brown and colleagues. Cochrane Database of Systematic Reviews 2020, Issue 6. Art. No.: CD000343. DOI: 10.1002/14651858.CD000343.pub4. The data do not suggest other benefits or harms and provide low-certainty evidence suggesting effects of multi-nutrient fortification on the risk of necrotizing enterocolitis in preterm infants (typical RR 1.37, 95% CI 0.72 to 2.63; 13 studies, 1110 infants).
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Multi-nutrient fortification of human milk for preterm infants Brown and colleagues. Cochrane Database of Systematic Reviews 2020, Issue 6. Art. No.: CD000343. DOI: 10.1002/14651858.CD000343.pub4. Authors' conclusions Feeding preterm infants with multi-nutrient fortified human breast milk compared with unfortified human breast milk is associated with modest increases in in-hospital growth rates. Evidence is insufficient to show whether multi-nutrient fortification has any effect on long-term growth or neurodevelopment.
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Human milk-derived fortifier versus bovine milk-derived fortifier for prevention of mortality and morbidity in preterm neonates. Premkumar MH, Pammi M, Suresh G. Cochrane Database of Systematic Reviews 2019, Issue 11. Art. No.: CD013145. DOI: 10.1002/14651858.CD013145.pub2. Optimizing nutritional content: Evidence from Cochrane systematic reviews
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Premkumar and colleagues. Cochrane Database of Systematic Reviews 2019, Issue 11. Art. No.: CD013145. DOI: 10.1002/14651858.CD013145.pub2. Human milk-derived fortifier versus bovine milk-derived fortifier for prevention of mortality and morbidity in preterm neonates. Preterm infants who are fed breast milk in comparison to infant formula have decreased morbidity such as necrotizing enterocolitis. Multi-nutrient fortifiers used to increase the nutritional content of the breast milk are commonly derived from bovine milk. Human milk-derived multi-nutrient fortifier is now available, but it is not clear if it improves outcomes in preterm infants fed with breast milk. Objectives: To determine whether the fortification of breast milk feeds with human milk-derived fortifier in preterm infants reduces mortality, morbidity, and promotes growth and development compared to bovine milk-derived fortifier. Selection criteria: We included randomized and quasi-randomized controlled trials that compared preterm infants fed breast milk fortified with human milk-derived fortifier versus those fed with breast milk fortified with bovine milk-derived fortifier.
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One trial involving 127 infants. Premkumar and colleagues. Cochrane Database of Systematic Reviews 2019, Issue 11. Art. No.: CD013145. DOI: 10.1002/14651858.CD013145.pub2. Human milk-derived fortifier versus bovine milk-derived fortifier for prevention of mortality and morbidity in preterm neonates.
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Premkumar and colleagues. Cochrane Database of Systematic Reviews 2019, Issue 11. Art. No.: CD013145. DOI: 10.1002/14651858.CD013145.pub2. Human milk-derived fortifier versus bovine milk-derived fortifier for prevention of mortality and morbidity in preterm neonates. Human milk-based fortifier did not decrease the risk of necrotizing enterocolitis in exclusively breast milk-fed preterm infants (RR 0.95, 95% CI 0.2 to 4.54; 1 study, 125 infants, low certainty of evidence). Human milk-derived fortifiers did not improve growth, decrease feeding intolerance, late-onset sepsis, or death.
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Premkumar and colleagues. Cochrane Database of Systematic Reviews 2019, Issue 11. Art. No.: CD013145. DOI: 10.1002/14651858.CD013145.pub2. Human milk-derived fortifier versus bovine milk-derived fortifier for prevention of mortality and morbidity in preterm neonates. Authors' conclusions There is insufficient evidence evaluating human milk-derived fortifier with bovine milk-derived fortifier in exclusively breast milk-fed preterm infants. Low-certainty evidence from one study suggests that in exclusively breast milk-fed preterm infants human milk-derived fortifiers in comparison with bovine milk-derived fortifier may not change the risk of necrotizing enterocolitis, mortality, feeding intolerance, infection, or improve growth. Well-designed randomized controlled trials are needed to evaluate short-term and long-term outcomes.
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Early fortification of human milk versus late fortification to promote growth in preterm infants Thanigainathan S, Abiramalatha T. Cochrane Database of Systematic Reviews 2020, Issue 7. Art. No.: CD013392. DOI: 10.1002/14651858.CD013392.pub2. Optimizing nutritional content: Evidence from Cochrane systematic reviews
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Early fortification of human milk versus late fortification to promote growth in preterm infants Thanigainathan and Abiramalath. Cochrane Database of Systematic Reviews 2020, Issue 7. Art. No.: CD013392. DOI: 10.1002/14651858.CD013392.pub2. Uncertainty exists about the optimal point at which multi-component fortifier should be added to human milk for promoting growth in preterm infants. The most common practice is to start fortification when the infant’s daily enteral feed volume reaches 100 mL/kg body weight. Another approach is to commence fortification earlier, in some cases as early as the first enteral feed. Early fortification of human milk could increase nutrient intake and growth rates but may increase the risk of feed intolerance and necrotizing enterocolitis (NEC). Objectives: To assess effects on growth and safety of early fortification of human milk versus late fortification in preterm infants To assess whether effects vary based upon gestational age (≤ 27 weeks; 28 to 31 weeks; ≥ 32 weeks), birth weight (< 1000 g; 1000 to 1499 g; ≥ 1500 g), small or appropriate for gestational age, or type of fortifier (bovine milk-based human milk fortifier (HMF); human milk-based HMF; formula powder) Selection criteria: We included randomized controlled trials that compared early versus late fortification of human milk in preterm infants. We defined early fortification as fortification started at < 100 mL/kg/d enteral feed volume or < 7 days postnatal age, and late fortification as fortification started at ≥ 100 mL/kg/d feeds or ≥ 7 days postnatal age.
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Two trials involving 237 infants. Thanigainathan and Abiramalath. Cochrane Database of Systematic Reviews 2020, Issue 7. Art. No.: CD013392. DOI: 10.1002/14651858.CD013392.pub2. Early fortification of human milk versus late fortification to promote growth in preterm infants
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Early fortification of human milk versus late fortification to promote growth in preterm infants Thanigainathan and Abiramalath. Cochrane Database of Systematic Reviews 2020, Issue 7. Art. No.: CD013392. DOI: 10.1002/14651858.CD013392.pub2. Main results We included two trials with a total of 237 infants. All participants were very low birth weight infants (birth weight < 1500 g). Early fortification was started at 20 mL/kg/d enteral feeds in one study and 40 mL/kg/d in the other study. Late fortification was started at 100 mL/kg/d feeds in both studies. One study used bovine milk-based fortifier, and the other used human milk-based fortifier.
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Early fortification of human milk versus late fortification to promote growth in preterm infants
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Early fortification of human milk versus late fortification to promote growth in preterm infants Thanigainathan and Abiramalath. Cochrane Database of Systematic Reviews 2020, Issue 7. Art. No.: CD013392. DOI: 10.1002/14651858.CD013392.pub2. Authors' conclusions Available evidence is insufficient to support or refute early fortification of human milk in preterm infants. Further large trials would be needed to provide data of sufficient quality and precision to inform policy and practice.
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Individualized versus standard diet fortification for growth and development in preterm infants receiving human milk Fabrizio V, Trzaski JM, Brownell EA, Esposito P, Lainwala S, Lussier MM, Hagadorn JI. Cochrane Database of Systematic Reviews 2020, in press. Art. No.: CD013465. DOI: 10.1002/14651858.CD013465. Optimizing nutritional content: Evidence from Cochrane systematic reviews
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Individualized versus standard diet fortification for growth and development in preterm infants receiving human milk Human milk as compared to formula reduces morbidity in preterm infants but requires fortification to meet their nutritional needs and to reduce the risk of extrauterine growth failure. Standard fortification methods are not individualized to the infant and assume that breast milk is uniform in nutritional content. Strategies for individualizing fortification are available; however it is not known whether these are safe, or if they improve outcomes in preterm infants. Objectives: To determine whether individualizing fortification of breast milk feeds in response to infant blood urea nitrogen (adjustable fortification) or to breast milk macronutrient content as measured with a milk analyzer (targeted fortification) reduces mortality and morbidity and promotes growth and development compared to standard, non-individualized fortification for preterm infants receiving human milk at < 37 weeks' gestation or at birth weight < 2500 grams. Selection criteria: We considered randomized, quasi-randomized, and cluster-randomized controlled trials of preterm infants fed exclusively breast milk that compared a standard non-individualized fortification strategy to individualized fortification using a targeted or adjustable strategy. We considered studies that examined any use of fortification in eligible infants for a minimum duration of two weeks, initiated at any time during enteral feeding, and providing any regimen of human milk feeding. Fabrizio and colleagues. Cochrane Database of Systematic Reviews 2020, in press. Art. No.: CD013465. DOI: 10.1002/14651858.CD013465.
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Seven trials involving 521 infants. Fabrizio and colleagues. Cochrane Database of Systematic Reviews 2020, in press. Art. No.: CD013465. DOI: 10.1002/14651858.CD013465. Individualized versus standard diet fortification for growth and development in preterm infants receiving human milk
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Individualized versus standard diet fortification for growth and development in preterm infants receiving human milk Fabrizio and colleagues. Cochrane Database of Systematic Reviews 2020, in press. Art. No.: CD013465. DOI: 10.1002/14651858.CD013465.
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Individualized versus standard diet fortification for growth and development in preterm infants receiving human milk Fabrizio and colleagues. Cochrane Database of Systematic Reviews 2020, in press. Art. No.: CD013465. DOI: 10.1002/14651858.CD013465.
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Individualized versus standard diet fortification for growth and development in preterm infants receiving human milk Authors' conclusions We found moderate- to low-certainty evidence suggesting that individualized (either targeted or adjustable) fortification of enteral feeds in very low birth weight infants increases growth velocity of weight, length, and head circumference during the intervention compared with standard non-individualized fortification. Evidence showing important in-hospital and post-discharge clinical outcomes was sparse and of very low certainty, precluding inferences regarding safety or clinical benefits beyond short-term growth.
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Guest Discussants Brenda Poindexter, MD, MS Professor, Emory University School of Medicine Chief of Neonatology, Children’s Healthcare of Atlanta Bill McGuire Professor, Hull York Medical School Coordinating Editor Cochrane Neonatal
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Questions regarding optimizing nutrition in preterm infants…. Where does the evidence take us? What are best “practices” regarding fortification / supplementation of feeds? What future research is urgently needed?
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Evidence in practice:Optimizing nutritional content of enteral nutrition for preterm infants Roger F. Soll, MD H. Wallace Professor of Neonatology Larner College of Medicine, University of Vermont Coordinating Editor, Cochrane Neonatal President, Vermont Oxford Network 1
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Guest Discussants Brenda Poindexter, MD, MS Professor, Emory University School of Medicine Chief of Neonatology, Children’s Healthcare of Atlanta Bill McGuire Professor, University of York, UK Coordinating Editor Cochrane Neonatal
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Moderator Danielle Ehret, MD, MPH Associate Professor, University of Vermont Director, Global Health, Vermont Oxford Network
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Sponsors Section on Neonatal-Perinatal Medicine
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Sponsors Cochrane Neonatal received unrestricted grant support to update reviews on feeding preterm infants from the Gerber Foundation
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Disclosure Roger F. Soll, M.D. is the Vice President of the Vermont Oxford Network and the Coordinating Editor of Cochrane Neonatal No other relevant financial issues to disclose Optimizing nutritional content of enteral nutrition for preterm infants
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To develop an understanding of the strengths and weaknesses of evidence provided by systematic reviews and meta-analyses to inform our practice of neonatal-perinatal medicine. Today’s focus will be on optimizing nutrition through supplementation and fortification. Optimizing nutritional content: Evidence from Cochrane systematic reviews
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How to Participate in Today’s Webinar Type questions you have into the chat box at anytime during the presentation. Use Poll Everywhere to answer questions posed during the session.
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* Pollev.com/vtoxford vtoxford + your response 22333 Three ways to use Poll Everywhere Text voting Web voting Open your web browser and type in pollev.com/vtoxford Download the app Poll Everywhere on your phone. After it is installed open and select Join Presentation and type in vtoxford Text vtoxford to 22333
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Have you ever participated in a Cochrane Neonatal Web Seminar? Yes No I can’t remember Have you ever participated in a Cochrane Neonatal Web Seminar?
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American Academy of Pediatrics Committee on Nutrition: Nutritional needs of low-birth-weight infants. Pediatrics. 1985;76:976–986. Goal of Nutrition for Preterm Infants Most neonatologists have accepted the recommendation of the American Academy of Pediatrics that growth of the postnatal preterm infant, both their anthropometric indices and body composition, should be the same as the normal fetus of the same gestational age growing in its mother’s uterus. In reality, this proves to be a challenge……
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What is the average weight gain of a fetus during the third trimester? 10 grams/day 25 grams/day 50 grams/day 75 grams/day Weight gain in the third trimester
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The World Health Organization fetal growth charts: concept, findings, interpretation, and application Torvid Kiserud, MD, PhD, Alexandra Benachi, MD, PhD, Kurt Hecher, MD, Rogelio González Perez, MD, José Carvalho, PhD, Gilda Piaggio, PhD, Lawrence D. Platt, MD AJOG 2018 Volume 218 Issue 2 Supplement S619-S629 DOI: https://doi.org/10.1016/j.ajog.2017.12.010
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Fetal weight gain in low-risk pregnancies showed little variation in the late third trimester, with a mean increment in estimated fetal weight of 24–26 g/day
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What percentage of very low birth weight infants experience severe postnatal growth failure (defined as a discharge weight less than the third percentile for postmenstrual age)? 5% 10% 30% 50% Severe postnatal growth failure
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Reports from NICUs across the world demonstrate that we have considerable room for improvement. The growth of nearly all preterm infants during their hospitalization in intensive care, especially those at the earliest gestational ages, lag far behind fetal growth curves in the third trimester. In the Vermont Oxford Network database, 31% of VLBW infants have extreme growth failure, defined as being less than the 3rd percentile on the Fenton Growth Chart at discharge. However, this failure in sustaining adequate growth varies greatly between centers (1st quartile 20%, 3rd quartile 40%). Optimizing nutritional content: Evidence from Cochrane systematic reviews
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What is the average growth velocity for very low birth weight infants? 10 grams/kg/day 12 grams/kg/day 18 grams/kg/day 20 grams/kg/day Growth velocity (grams/kg/day)
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Weight Growth Velocity and Postnatal Growth Failure in Infants 501 to 1500 Grams: 2000–2013 Jeffrey D. Horbar, Richard A. Ehrenkranz, Gary J. Badger, Erika M. Edwards, Kate A. Morrow, Roger F. Soll, Jeffrey S. Buzas, Enrico Bertino, Luigi Gagliardi and Roberto Bellù Pediatrics July 2015, 136 (1) e84-e92; DOI: https://doi.org/10.1542/peds.2015-0129
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BACKGROUND: Very low birth weight infants often gain weight poorly and demonstrate growth failure during the initial hospitalization. Although many of the major morbidities experienced by these infants during their initial NICU stays have decreased in recent years, it is unclear whether growth has improved. METHODS: We studied 362 833 infants weighing 501 to 1500 g without major birth defects born from 2000 to 2013 and who were hospitalized for 15 to 175 days at 736 North American hospitals in the Vermont Oxford Network. Average growth velocity (GV; g/kg per day) was computed by using a 2-point exponential model on the basis of birth weight and discharge weight. Postnatal growth failure and severe postnatal growth failure were defined as a discharge weight less than the 10th and third percentiles for postmenstrual age, respectively. RESULTS: From 2000 to 2013, average GV increased from 11.8 to 12.9 g/kg per day. Postnatal growth failure decreased from 64.5% to 50.3% and severe postnatal growth failure from 39.8% to 27.5%. The interquartile ranges for the hospitals participating in 2013 were as follows: GV, 12.3 to 13.4 g/kg per day; postnatal growth failure, 41.1% to 61.7%; and severe postnatal growth failure, 19.4% to 36.0%.
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Growth velocity during an ELBW infant’s NICU hospitalization exerts a significant effect on neurodevelopmental and growth outcomes at 18 to 22 months’ corrected age. True False Uncertain Growth velocity and longer term outcome
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Growth in the Neonatal Intensive Care Unit Influences Neurodevelopmental and Growth Outcomes of Extremely Low Birth Weight Infants Richard A. Ehrenkranz, Anna M. Dusick, Betty R. Vohr, Linda L. Wright, Lisa A. Wrage, W. Kenneth Poole and ; for the National Institutes of Child Health and Human Development Neonatal Research Network Pediatrics April 2006, 117 (4) 1253-1261; DOI: https://doi.org/10.1542/peds.2005-1368
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METHODS. Infants 501 to 1000 g birth weight from a multicenter cohort study were divided into quartiles of in-hospital growth velocity rates. Variables considered for the logistic-regression models included sex, race, gestational age, small for gestational age, mother’s education, severe intraventricular hemorrhage, periventricular leukomalacia, age at regaining birth weight, necrotizing enterocolitis, late-onset infection, bronchopulmonary dysplasia, postnatal steroid therapy for pulmonary disease, and center. RESULTS. Of the 600 discharged infants, 495 (83%) were evaluated at 18 to 22 months’ corrected age. As the rate of weight gain increased between quartile 1 and quartile 4, from 12.0 to 21.2 g/kg per day, the incidence of cerebral palsy, Bayley II Mental Developmental Index (MDI) < 70 and Psychomotor Developmental Index (PDI) <70, abnormal neurologic examination, neurodevelopmental impairment, and need for rehospitalization fell significantly. The in-hospital rate of growth was associated with the likelihood of anthropometric measurements at 18 months’ corrected age below the 10th percentile values of the Centers for Disease Control and Prevention 2000 growth curve. Logistic-regression analyses, controlling for potential demographic or clinical cofounders, and adjusted for center, identified a significant relationship between growth velocity and the likelihood of cerebral palsy, MDI and PDI scores of < 70, and neurodevelopmental impairment.
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What to actually do?
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Does your center have specific written guidelines regarding fortification of feeds in very low birth weight infants? Yes No Uncertain What’s your policy?
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Variation in practice A great deal of variation is seen in feeding practices worldwide. (Klingenberg and colleagues. Arch Dis Child 2012). For example, 69% of units in the UK and Ireland routinely use human milk fortifier, whereas 100% of units in Canada report routine use. Optimizing nutritional content: Evidence from Cochrane systematic reviews
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Current trials demonstrate increased growth velocity in preterm infants fed increased protein fortification. Yes No Uncertain Fortification and growth parameters
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Growth velocity Are these increases in growth velocity clinically meaningful? What do our experts think?
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Use of milk “fortifiers” Our center fortifies mother’s own milk or donor breast milk with Human milk-derived fortifier Bovine milk-derived fortifier Either (depending on criteria established in guidelines)
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Premkumar and colleagues. Cochrane Database of Systematic Reviews 2019, Issue 11. Art. No.: CD013145. DOI: 10.1002/14651858.CD013145.pub2. Human milk-derived fortifier versus bovine milk-derived fortifier for prevention of mortality and morbidity in preterm neonates. Human milk-based fortifier did not decrease the risk of necrotizing enterocolitis in exclusively breast milk-fed preterm infants (RR 0.95, 95% CI 0.2 to 4.54; 1 study, 125 infants, low certainty of evidence). Human milk-derived fortifiers did not improve growth, decrease feeding intolerance, late-onset sepsis, or death.
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Our center has policies or guidelines for individualized (adjusted or targeted) diet fortification Yes No Uncertain [Note: individualized fortification of breast milk feeds includes adjustable fortification (in response to infant blood urea nitrogen) or targeted fortification (to breast milk macronutrient content as measured with a milk analyzer)] Individualized versus standard diet fortification
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Individualized versus standard diet fortification for growth and development in preterm infants receiving human milk Fabrizio and colleagues. Cochrane Database of Systematic Reviews 2020, in press. Art. No.: CD013465. DOI: 10.1002/14651858.CD013465.
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W. McGuire What constitutes best practice? What do our experts feel constitutes best practice? What practices do you think represent our best efforts at optimizing nutrition (and what evidence lies behind these beliefs)?
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W. McGuire What constitutes best practice? What trials do we need to establish best practices to optimize nutrition?
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Much more work to be done! We look forward to meeting with you again in 2021 to discuss the evidence behind current guidelines in neonatal care! Have a safe and happy holidays! Optimizing nutritional content of enteral nutrition for preterm infants
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CME Contact Hours: An email will be sent to all participants with links to post-webinar surveys. Upon completion of the survey, participants will receive their certificates. Surveys will be open for 2 weeks. Questions: colleen.ovelman@uvm.edu
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