Optimising growth in very preterm infants: reviewing the evidence

Abstract

Infants born before 32 weeks’ postmenstrual age are at a high risk of growth failure. International guidelines have long recommended that they match the growth of an equivalent fetus, despite the challenges posed by ex utero life and comorbidities of prematurity. Several groups have recently questioned the necessity or desirability of this target, shifting attention to aiming for growth which optimises important long-term outcomes. Specifically, recent research has identified the neurodevelopmental benefits of enhanced growth during the neonatal period, but work in term infant suggests that rapid growth may promote the metabolic syndrome in later life. In this context, defining a pattern of growth which optimises outcomes is complex, controversial and contested. Even if an optimal pattern of growth can be defined, determining the nutritional requirements to achieve such growth is not straightforward, and investigations into the nutritional needs of the very preterm infant continue. Furthermore, each infant has individual nutritional needs and may encounter a number of barriers to achieving good nutrition. This article offers a narrative review of recent evidence for the competing definitions of optimal growth in this cohort. It examines recent advances in the determination of macronutrient and micronutrient intake targets along with common barriers to achieving good nutrition and growth. Finally, key implications for clinical practice are set out and a recommendation for structured multidisciplinary management of nutrition and growth is illustrated.

Biomarker und Neuromonitoring zur Entwicklungsprognose nach perinataler Hirnschädigung

“…Genetische Prädispositionen wie Apolipoprotein(Apo)-E-Polymorphismen wiederum sind Risikofaktoren für das Auftreten einer intraventrikulären Blutung und auch für die spätere Entwicklung einer CP, wie in einer gemeinsamen Studie mit den German Neonatal Network (GNN) gezeigt wurde [ 26 , 46 ]. Auch die Art der Ernährung, insbesondere mit Muttermilch, hat einen entscheidenden Einfluss auf die Entwicklung und sollte einbezogen werden [ 108 ].…”

A Scoping Review: Urinary Markers of Metabolic Maturation in Preterm Infants and Future Interventions to Improve Growth

“…Globally, an estimated 15 million infants are born preterm (before 37 weeks gestational age) each year, with a prevalence of 5 to 18% depending on country of birth [ 1 ]. Current recommendations suggest the growth of preterm infants should aim to approximate the in utero growth of infants of the equivalent gestation [ 2 , 3 , 4 ], although defining optimal growth relative to short and long term outcomes continues to be debated [ 5 ]. During the first 1000 days growth not only involves increasing weight and body length, but also rapid maturation of the immune system, endocrine system and metabolic pathways [ 6 , 7 , 8 ].…”

“…During the first 1000 days growth not only involves increasing weight and body length, but also rapid maturation of the immune system, endocrine system and metabolic pathways [ 6 , 7 , 8 ]. Post-natal growth failure in preterm infants is a persistent problem and may result in poorer neurocognitive outcomes [ 5 ], as well as increasing the risk of morbidity and mortality [ 5 , 9 , 10 ]. Conversely rapid weight gain, particularly between 2.5 and 6 years of age, is associated with the development of metabolic syndrome and cardiovascular disease later in life [ 11 , 12 ].…”

“…Conversely rapid weight gain, particularly between 2.5 and 6 years of age, is associated with the development of metabolic syndrome and cardiovascular disease later in life [ 11 , 12 ]. Reasons for constrained growth are numerous but may include (i) failure to deliver sufficient nutrition, (ii) intestinal immaturity resulting in alterations of nutrient utilisation by the intestine or losses via renal system, (iii) metabolic immaturity leading to transient intolerance of lipids and glucose, (iv) dysregulated maturation of metabolic pathways and urinary losses of important metabolites, (v) dysbiosis of the microbiome with poor diversity and low abundance of intestinal microbiota, (vi) medical management including use of pharmacopeia (i.e., diuretics) increasing urinary losses of electrolytes and (vii) disruption in achieving nutrition targets [ 5 , 6 , 13 , 14 , 15 ].…”

“…Although there are well established nutritional recommendations from various expert groups pertaining to macro- and micronutrient requirements of preterm infants [ 4 , 16 ], the recommendations do not account for an individual preterm infant’s ability to assimilate nutrients or the ability to overcome potential aberrance in metabolic pathways [ 5 , 9 , 17 ]. As an example, some preterm infants, (especially those around the threshold of viability) experience metabolic immaturity and instability leading to sustained periods of hyperglycaemia and hypertriglyceridemia, meaning that some nutritional goals are not met during a time of rapid growth and organ development [ 9 , 17 ].…”