There is an association between preterm birth and IS throughout the life course, but the data are conflicting and associations are likely to be affected by the heterogeneity of each study population and multiple confounding factors that may change over time. While the optimal nutritional strategy for preterm infants remains to be determined, standard public health guidance to avoid obesogenic lifestyle factors remains equally important to individuals born preterm.

Alkaline phosphatase (ALP) is regularly measured in clinical practice. Changes in serum levels are observed in a number of clinical conditions. In neonatology, it has been proposed as a useful marker for both a diagnosis and an indication of the severity of metabolic bone disease (MBD) in infants born preterm. Nutritional practices, aimed at reducing the occurrence or severity of MBD, have led to ALP being proposed as a stand-alone means of monitoring treatment. The current evidence does not support this use: ALP only achieves usefulness in a diagnostic and monitoring capacity when combined with other serum and imaging techniques.

We would like to comment on, and correct some misunderstandings in, the paper by Foy et al., which suggests that there are major gaps in optimal airway management in neonatal intensive care units (NICUs) in the UK, particularly lack of continuous waveform capnography and/or videolarygoscopy [1]. We are in full agreement with the NHS Improvement recommendation that undetected oesophageal intubation should be a 'Never Event', but note that detection of this event relates mostly to the use of capnography at intubation, rather than during ongoing ventilatory support.It is well recognised that detection of exhaled CO 2 using a colorimetric device facilitates confirmation of tracheal tube placement in newborn babies, despite being subject to both false-positive and false-negative results, and this is recommended by international guidelines [2]. A recent survey of UK neonatal units reported routine use of CO 2 monitoring in 84-88% of neonatal intubations in the labour ward [3], considerably at odds with the reported availability of 'capnography' of between 18% and 48% in Foy et al.'s paper. The phrase 'continuous waveform capnography' may not be one with which most staff working in a UK NICU will be familiar, and it is not clear from the paper whether the question regarding capnography was, or could have been, interpreted as including single use colorimetric CO 2 detector devices at neonatal intubation. Based on a single personal communication, Foy et al. state that capnography is 'routinely' used in 'many' neonatal transfers. This contradicts data presented in Fig. 2, but accords with a recent informal survey of 15 UK transport services, of which 13 routinely use capnography (personal communication -Dr A. Jackson). The transport neonatal population differs in several regards from the NICU population and continuous waveform capnography may be more useful in sedated babies, and when the environment means that the ventilator may not reliably produce flowgraphs. As acknowledged by Foy et al., there is no evidence of reduction in harm from intubation with the use of continuous waveform capnography in the NICU. Interpretation of continuous waveform capnography is likely to be complicated by the fast ventilator rates and short expiry time used in neonates, routine use of uncuffed tracheal tubes and the relatively large dead space in the smallest preterm infants. Most neonatal ventilators now incorporate flow graphs, with which neonatal nursing and medical staff are familiar, and which provide an opportunity to recognise accidental extubation. There has been no direct comparison of continuous waveform capnography and ventilator flow graphs in terms of efficacy and safety in ventilated preterm infants. Videolaryngoscopy has potential to facilitate teaching and practice of neonatal intubation [4] and videolaryngoscopes suitable for very preterm infants are now available. We anticipate therefore that availability of and (just as importantly) familiarity with videolaryngoscopy within UK neonatal units will continue to increase alt...

BackgroundPreterm infants represent up to 10% of births worldwide and have an increased risk of adverse metabolic outcomes in later life. Early life exposures are key factors in determining later health but current lifestyle factors such as diet and physical activity are also extremely important and provide an opportunity for targeted intervention.Methods/DesignThis current study, GROWMORE, is the fourth phase of the Newcastle Preterm Birth Growth Study (PTBGS), which was formed from two randomised controlled trials of nutrition in early life in preterm (24–34 weeks gestation) and low birthweight infants. 247 infants were recruited prior to hospital discharge. Infant follow-up included detailed measures of growth, nutritional intake, morbidities and body composition (Dual X Ray Absorptiometry, DXA) along with demographic data until 2 years corrected age. Developmental assessment was performed at 18 months corrected age, and cognitive assessment at 9–10 years of age. Growth, body composition (DXA), blood pressure and metabolic function (insulin resistance and lipid profile) were assessed at 9–13 years of age, and samples obtained for epigenetic analysis. In GROWMORE, we will follow up a representative cohort using established techniques and novel metabolic biomarkers and correlate these with current lifestyle factors including physical activity and dietary intake. We will assess auxology, body composition (BODPOD™), insulin resistance, daily activity levels using Actigraph™ software and use 31P and 1H magnetic resonance spectroscopy to assess mitochondrial function and intra-hepatic lipid content.DiscussionThe Newcastle PTBGS is a unique cohort of children born preterm in the late 1990’s. The major strengths are the high level of detail of early nutritional and growth exposures, and the comprehensive assessment over time. This study aims to examine the associations between early life exposures in preterm infants and metabolic outcomes in adolescence, which represents an area of major translational importance.