Impact of introducing a standardized nutrition protocol on very premature infants' growth and morbidity

Apolline Wittwer, Jean-Michel Hascoët, Apolline Wittwer, Jean-Michel Hascoët

Abstract

Background: Inappropriate nutritional intake in premature infants may be responsible for postnatal growth restriction (PGR) and adverse long-term outcomes.

Objective: We evaluated the impact of an updated nutrition protocol on very premature infants' longitudinal growth and morbidity, and secondly the compliance to this new protocol.

Design: All infants born between 26-32 weeks gestation (GA) were studied retrospectively during two 6-month periods before (group 1) and after (group 2) the introduction of an optimized nutrition protocol, in a longitudinal comparative analysis.

Results: 158 infants were included; 72 before and 86 after the introduction of the protocol (Group 1: (mean±SD) birthweight (BW) 1154±276 g, GA 29.0±1.4 weeks; Group 2: BW 1215±332 g, GA 28.9±1.7 weeks). We observed growth improvement in Group 2 more pronounced in males (weight z-score) at D42 (-1.688±0.758 vs. -1.370±0.762, p = 0.045), D49 (-1.696±0.776 vs. -1.370±0.718, p = 0.051), D56 (-1.748±0.855 vs. -1.392±0.737, p = 0.072), D63 (-1.885±0.832 vs. -1.336±0.779 p = 0.016), and D70 (-2.001±0.747 vs. -1.228±0.765 p = 0.004). There was no difference in females or in morbidities between the groups. We observed low compliance to the protocol in both groups: similar energy intake but higher lipid intake in Group 1 and higher protein intake in Group 2.

Conclusion: The quality of nutritional care with a strictly-defined protocol may significantly improve weight gain for very preterm infants. As compliance remained low, an educational reinforcement is needed to prevent PGR.

Clinical trial registration: This retrospective study was registered by ClinicalTrials.gov under number NCT03217045, and by the CNIL (Commission Nationale de l'Informatique et des Libertés) under study number R2015-1 for the Maternity of the CHRU of Nancy.

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1. Longitudinal weight z-score evolution from…
Fig 1. Longitudinal weight z-score evolution from birth to day 77.
D = day, *p

Fig 2

A: Longitudinal weight z-score evolution…

Fig 2

A: Longitudinal weight z-score evolution from birth to day 77 in males. D…

Fig 2
A: Longitudinal weight z-score evolution from birth to day 77 in males. D = day, *p 0.05 for all values.

Fig 3

A: Longitudinal weight delta z-score…

Fig 3

A: Longitudinal weight delta z-score evolution from birth to day 77 in males.…

Fig 3
A: Longitudinal weight delta z-score evolution from birth to day 77 in males. D = day, p > 0.05 for all values. B: Longitudinal weight delta z-score evolution from birth to day 77 in males. D = day, p > 0.05 for all values.

Fig 4. Median and variability (IQR) for…

Fig 4. Median and variability (IQR) for (A) energy, (B) protein, and (C) lipid intakes…

Fig 4. Median and variability (IQR) for (A) energy, (B) protein, and (C) lipid intakes from birth to day 42.
D = day, *p
Similar articles
Cited by
References
    1. Cooke R. Postnatal Growth in Preterm Infants: Have We Got it Right? J Perinatol 2005;25(S2):S12–4. - PubMed
    1. Embleton NE, Pang N, Cooke RJ. Postnatal malnutrition and growth retardation: an inevitable consequence of current recommendations in preterm infants? Pediatrics 2001;107(2):270–3. 10.1542/peds.107.2.270 - DOI - PubMed
    1. Grover A, Khashu M, Mukherjee A, et al. Iatrogenic malnutrition in neonatal intensive care units: urgent need to modify practice. J Parenter Enteral Nutr 2008;32(2):140–4. - PubMed
    1. Senterre T, Rigo J. Reduction in postnatal cumulative nutritional deficit and improvement of growth in extremely preterm infants: Nutritional deficit and growth in preterm infants. Acta Paediatr 2012;101(2):e64–70. 10.1111/j.1651-2227.2011.02443.x - DOI - PubMed
    1. Lee PA, Chernausek SD, Hokken-Koelega ACS, Czernichow P. International Small for Gestational Age Advisory Board Consensus Development Conference Statement: Management of Short Children Born Small for Gestational Age. Pediatrics 2003;111(6):1253–61. - PubMed
Show all 32 references
Publication types
MeSH terms
Associated data
Related information
Grants and funding
The authors received no specific funding for this work.
[x]
Cite
Copy Download .nbib .nbib
Format: AMA APA MLA NLM
Fig 2
Fig 2
A: Longitudinal weight z-score evolution from birth to day 77 in males. D = day, *p 0.05 for all values.
Fig 3
Fig 3
A: Longitudinal weight delta z-score evolution from birth to day 77 in males. D = day, p > 0.05 for all values. B: Longitudinal weight delta z-score evolution from birth to day 77 in males. D = day, p > 0.05 for all values.
Fig 4. Median and variability (IQR) for…
Fig 4. Median and variability (IQR) for (A) energy, (B) protein, and (C) lipid intakes from birth to day 42.
D = day, *p

References

    1. Cooke R. Postnatal Growth in Preterm Infants: Have We Got it Right? J Perinatol 2005;25(S2):S12–4.
    1. Embleton NE, Pang N, Cooke RJ. Postnatal malnutrition and growth retardation: an inevitable consequence of current recommendations in preterm infants? Pediatrics 2001;107(2):270–3. 10.1542/peds.107.2.270
    1. Grover A, Khashu M, Mukherjee A, et al. Iatrogenic malnutrition in neonatal intensive care units: urgent need to modify practice. J Parenter Enteral Nutr 2008;32(2):140–4.
    1. Senterre T, Rigo J. Reduction in postnatal cumulative nutritional deficit and improvement of growth in extremely preterm infants: Nutritional deficit and growth in preterm infants. Acta Paediatr 2012;101(2):e64–70. 10.1111/j.1651-2227.2011.02443.x
    1. Lee PA, Chernausek SD, Hokken-Koelega ACS, Czernichow P. International Small for Gestational Age Advisory Board Consensus Development Conference Statement: Management of Short Children Born Small for Gestational Age. Pediatrics 2003;111(6):1253–61.
    1. Barker DJ. Intrauterine programming of coronary heart disease and stroke. Acta Paediatr Suppl 1997;423:178–82. 10.1111/j.1651-2227.1997.tb18408.x
    1. Smart JL, Dobbing J, Adlard BP, et al. Vulnerability of developing brain: relative effects of growth restriction during the fetal and suckling periods on behavior and brain composition of adult rats. J Nutr 1973;103(9):1327–38. 10.1093/jn/103.9.1327
    1. Ehrenkranz RA, Dusick AM, Vohr BR, et al. Growth in the neonatal intensive care unit influences neurodevelopmental and growth outcomes of extremely low birth weight infants. Pediatrics 2006;117(4):1253–61. 10.1542/peds.2005-1368
    1. Monset-Couchard M, de Bethmann O, Kastler B. Mid- and long-term outcome of 166 premature infants weighing less than 1,000 g at birth, all small for gestational age. Biol Neonate 2002;81(4):244–54. 10.1159/000056755
    1. Dusick AM, Poindexter BB, Ehrenkranz RA, Lemons JA. Growth failure in the preterm infant: can we catch up? Semin Perinatol 2003;27(4):302–10. 10.1016/s0146-0005(03)00044-2
    1. Andrews ET, Ashton JJ, Pearson F, et al. Early postnatal growth failure in preterm infants is not inevitable. Arch Dis Child Fetal Neonatal Ed 2019;104(3):F235‑41. 10.1136/archdischild-2018-315082
    1. Roggero P, Giannì ML, Orsi A, et al. Implementation of Nutritional Strategies Decreases Postnatal Growth Restriction in Preterm Infants. PLoS ONE 2012;7(12):e51166 10.1371/journal.pone.0051166
    1. Rochow N, Fusch G, Mühlinghaus A, et al. A nutritional program to improve outcome of very low birth weight infants. Clin Nutr 2012;31(1):124–31. 10.1016/j.clnu.2011.07.004
    1. Nutrition and feeding of preterm infants. Committee on Nutrition of the Preterm Infant, European Society of Paediatric Gastroenterology and Nutrition. Acta Paediatr Scand Suppl 1987;336:1–14.
    1. Klein CJ. Nutrient requirements for preterm infant formulas. J Nutr 2002;132(6 Suppl 1):1395S–577S.
    1. Agostoni C, Buonocore G, Carnielli VP, et al. Enteral nutrient supply for preterm infants: commentary from the European Society of Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition. J Pediatr Gastroenterol Nutr 2010;50(1):85–91. 10.1097/MPG.0b013e3181adaee0
    1. Lapillonne A, Razafimahefa H, Rigourd V, et al. [Nutrition of the preterm infant]. Arch Pediatr 2011;18(3):313–323. 10.1016/j.arcped.2010.12.006
    1. Senterre T, Rigo J. [Parenteral nutrition in premature infants: practical aspects to optimize postnatal growth and development]. Arch Pediatr 2013;20(9):986–93. 10.1016/j.arcped.2013.05.021
    1. Senterre T, Rigo J. Optimizing early nutritional support based on recent recommendations in VLBW infants and postnatal growth restriction. J Pediatr Gastroenterol Nutr 2011;53(5):536–42. 10.1097/MPG.0b013e31822a009d
    1. Olsen IE, Groveman SA, Lawson ML, et al. New intrauterine growth curves based on United States data. Pediatrics 2010;125(2):e214–224. 10.1542/peds.2009-0913
    1. Zozaya C, Díaz C, Saenz de Pipaon M. How Should We Define Postnatal Growth Restriction in Preterm Infants? Neonatology 2018;114(2):177–80. 10.1159/000489388
    1. Bell MJ, Ternberg JL, Feigin RD, et al. Neonatal necrotizing enterocolitis. Therapeutic decisions based upon clinical staging. Ann Surg 1978;187(1):1–7. 10.1097/00000658-197801000-00001
    1. Billard H, Simon L, Desnots E, et al. Calibration Adjustment of the Mid-infrared Analyzer for an Accurate Determination of the Macronutrient Composition of Human Milk. J Hum Lact 2016;32(3):19–27.
    1. Tremblay G, Boudreau C, Belanger S, et al. Body Composition in Very Preterm Infants: Role of Neonatal Characteristics and Nutrition in Achieving Growth Similar to Term Infants. Neonatology 2017;111(3):214–21. 10.1159/000450882
    1. Iacobelli S, Viaud M, Lapillonne A, et al. Nutrition practice, compliance to guidelines and postnatal growth in moderately premature babies: the NUTRIQUAL French survey. BMC Pediatr 2015;15:110 10.1186/s12887-015-0426-4
    1. Thomas EL, Parkinson JR, Hyde MJ, et al. Aberrant adiposity and ectopic lipid deposition characterize the adult phenotype of the preterm infant. Pediatr Res 2011;70(5):507–12. 10.1203/PDR.0b013e31822d7860
    1. Sudo N, Sawamura S, Tanaka K, et al. The requirement of intestinal bacterial flora for the development of an IgE production system fully susceptible to oral tolerance induction. J Immunol 1997;159(4):1739–45.
    1. Maas C, Poets CF, Franz AR. Avoiding postnatal undernutrition of VLBW infants during neonatal intensive care: evidence and personal view in the absence of evidence. Arch Dis Child Fetal Neonatal Ed. 2015;100(1):F76–81. 10.1136/archdischild-2014-306195
    1. Christmann V, Roeleveld N, Visser R, et al. The early postnatal nutritional intake of preterm infants affected neurodevelopmental outcomes differently in boys and girls at 24 months. Acta Paediatr 2017;106(2):242–9. 10.1111/apa.13669
    1. Hack M, Schluchter M, Margevicius S, et al. Trajectory and correlates of growth of extremely-low-birth-weight adolescents. Pediatr Res 2014;75(2):358–66. 10.1038/pr.2013.209
    1. Stefanescu BM, Gillam-Krakauer M, Stefanescu AR, et al. Very low birth weight infant care: adherence to a new nutrition protocol improves growth outcomes and reduces infectious risk. Early Hum Dev 2016;94:25–30. 10.1016/j.earlhumdev.2016.01.011
    1. Hascoet JM, Chauvin M, Pierret C, et al. Impact of Maternal Nutrition and Perinatal Factors on Breast Milk Composition after Premature Delivery. Nutrients 2019;11:E366 10.3390/nu11020366

Source: PubMed

Patrocinadores e Colaboradores

Condições médicas

Intervenções de drogas

3
Se inscrever