Postnatal Head Growth in Preterm Infants: A Randomized Controlled Parenteral Nutrition Study

Abstract

WHAT'S KNOWN ON THIS SUBJECT: Preterm infants dependent on parenteral nutrition are vulnerable to deficits in early postnatal nutritional intake. This coincides with a period of suboptimal head growth. Observational studies indicate that poor nutritional intake is associated with suboptimal head growth and neurodevelopmental outcome. WHAT THIS STUDY ADDS:This study provides randomized controlled trial evidence that head growth failure in the first 4 weeks of life can be ameliorated with early nutritional intervention. Early macronutrient intake can be enhanced by optimizing a standardized, concentrated neonatal parenteral nutrition regimen. abstract BACKGROUND: Early postnatal head growth failure is well recognized in very preterm infants (VPIs). This coincides with the characteristic nutritional deficits that occur in these parenteral nutrition (PN) dependent infants in the first month of life. Head circumference (HC) is correlated with brain volume and later neurodevelopmental outcome. We hypothesized that a Standardized, Concentrated With Added Macronutrients Parenteral (SCAMP) nutrition regimen would improve early head growth. The aim was to compare the change in HC (DHC) and HC SD score (DSDS) achieved at day 28 in VPIs randomly assigned to receive SCAMP nutrition or a control standardized, concentrated PN regimen. METHODS:Control PN (10% glucose, 2.8 g/kg per day protein/lipid) was started within 6 hours of birth. VPIs (birth weight ,1200 g; gestation ,29 weeks) were randomly assigned to either start SCAMP (12% glucose, 3.8 g/kg per day protein/lipid) or remain on the control regimen. HC was measured weekly. Actual daily nutritional intake data were collected for days 1 to 28.RESULTS: There were no differences in demographic data between SCAMP (n = 74) and control (n = 76) groups. Comparing cumulative 28-day intakes, the SCAMP group received 11% more protein and 7% more energy. The SCAMP group had a greater DHC at 28 days (P , .001). The difference between the means (95% confidence interval) for DHC was 5 mm (2 to 8), and DSDS was 0.37 (0.17 to 0.58). HC differences are still apparent at 36 weeks' corrected gestational age. Dr Morgan developed the original concept and designed the study, ensured regulatory approvals, performed some study measurements, data collection and collation, coordinated data analysis, and drafted the initial manuscript; Mr McGowan performed most of the study measurements, data collection, and collation, contributed to data analysis and made study design modifications; Mr Herwitker was involved with study design and regulatory approval, overseeing study PN manufacture, and some data collation; Ms Hart provided the medical statistical support at the design, monitoring, and analytical stages of the study; Dr Turner was involved in study design and data analysis; and all authors approved the final manuscript as submitted. CONCLUSIONS:This trial has been registered with the ISRCTN Register (http:// isrctn.org) (identifier ISRCTN76597892 Improved survival of very preterm infants (VPIs) ha...

Nutritional Evaluation and Optimisation in Neonates (NEON) trial of amino acid regimen and intravenous lipid composition in preterm parenteral nutrition: a randomised double-blind controlled trial

“…The observation is at odds with the Standardised, Concentrated Additional Macronutrients, Parenteral nutrition in very preterm infants (SCAMP) study, in which very preterm neonates randomised to receive higher PN from birth had a larger head circumference at 28 days. 68 Of note is that, although the SCAMP study aimed to deliver large amounts of PN, randomisation occurred up to 120 hours of age (compared with 24 hours in the NEON trial) and hence infants received a lower average energy and amino acid intake over the first 3 postnatal days than the NEON trial infants. The NEON trial was not powered to detect a difference in head circumference, but our observation is a concern as the possibility of adverse effects from higher PN has been raised previously.…”

Peripherally inserted central catheters optimize nutrient intake in moderately preterm infants

“…Numerous studies have shown the advantages of early nutrition and avoidance of protein deficits (10,(13)(14)(15). However, provision of adequate nutrition in the early postnatal period remains a challenge, and current clinical practices for the delivery of adequate nutrition may be insufficient (8,9,16,17).…”

“…In a recent study of very-low-birth-weight infants, an optimized parenteral nutrition regimen with increased protein improved early postnatal head growth compared to a standard parenteral nutrition regimen (10), suggesting that improvement of clinical nutrition practices may be crucial in improving outcomes for premature infants. Failure to "catch up" in the first 8 mo of life is associated with lower head circumference and higher rates of poor neurologic development in very-lowbirth-weight infants (11).…”

Dietary proteins and IGF I levels in preterm infants: determinants of growth, body composition, and neurodevelopment

“…During hospitalization increased protein intake improves head growth in preterm infants (66,67). Even so total energy and lipid intake also have been positively correlated with head growth (67,68).…”

“…Even so total energy and lipid intake also have been positively correlated with head growth (67,68). Nonetheless, Hansen-Pupp et al could not associate protein and caloric intake with brain volumes (39) and in several studies protein-enriched nutrition failed to improve neurodevelopmental outcome up to 18 mo corrected age (53,66,69,70).…”