Nutrition and the developing brain: the road to optimizing early neurodevelopment: a systematic review.

BACKGROUND: Neonatal intensive care practices have resulted in marked improvements in the survival of premature infants; however, they remain at significant risk for adverse neurodevelopmental outcomes. The impact of current nutritional practices on brain development following early extra-uterine exposure in premature infants is not well known. METHODS: We performed a systematic review to investigate nutritional effects on postnatal brain development in healthy term and prematurely born infants utilizing advanced magnetic resonance imaging tools. RESULTS: Systematic screen yielded 595 studies for appraisal. Of these, 22 total studies were selected for inclusion in the review, with findings summarized in a qualitative, descriptive fashion. CONCLUSION: Fat and energy intake are associated with improved brain volume and development in premature infants. While breast milk intake and long-chain polyunsaturated fatty acid supplementation has been proven beneficial in term infants, the impact in preterm infants is less well understood.

Improved brain growth and microstructural development in breast milk-fed very low birth weight premature infants.

AIM: Breast milk feeding is linked to improved neurodevelopmental outcomes in very low birth weight (VLBW) infants, though the mechanisms are not well understood. This study utilised quantitative magnetic resonance imaging (qMRI) techniques to compare brain growth and white matter development in preterm infants receiving primarily breast milk versus formula feeds. METHODS: We prospectively enrolled infants born at very low birth weight (<1500 g) and <32 weeks gestational age and performed MRI at term-equivalent age. We utilised volumetric segmentation to calculate regional and total brain volumes and diffusion tensor imaging to evaluate white matter microstructural organisation. Daily nutritional data were extracted from the medical record. RESULTS: Nutritional and MRI data were obtained for 68 infants admitted within the first week of life (44 breast milk and 24 formula). Breast milk-fed infants demonstrated significantly larger total brain volumes (P = .04) as well as volumes in the amygdala-hippocampus and cerebellum (P < .01) compared with formula-fed. Infants receiving breast milk also demonstrated greater white matter microstructural organisation in the corpus callosum, posterior limb of internal capsule and cerebellum (P < .01 to .03). CONCLUSION: VLBW infants receiving primarily breast milk versus preterm formula in this small exploratory study demonstrated significantly greater regional brain volumes and white matter microstructural organisation by term-equivalent age.

Early Glycemic Profile Is Associated with Brain Injury Patterns on Magnetic Resonance Imaging in Hypoxic Ischemic Encephalopathy.

OBJECTIVE: To investigate whether the early glycemic profile in infants with hypoxic ischemic encephalopathy is associated with distinct patterns of brain injury on magnetic resonance imaging (MRI). STUDY DESIGN: We performed a secondary analysis of 178 prospectively enrolled infants who received therapeutic hypothermia for hypoxic ischemic encephalopathy. Glycemic profiles were identified by glucose concentrations within 24 hours after birth: normoglycemia (all glucose concentrations of >47 to ≤150 mg/dL; n = 62); hypoglycemia (≥1 concentration ≤47 mg/dL; n = 17); hyperglycemia (≥1 concentration >150 mg/dL; n = 76); and labile glucose (both hypoglycemia and hyperglycemia; n = 23). Patterns of brain injury were identified for 151 infants based on Barkovich scores from the postrewarming brain MRIs at a median age of 9 days. RESULTS: A normal brain MRI was reported in 37 of 62 infants (60%) with normal blood glucose values compared with 37 of 116 infants (32%) with an abnormal glucose profile (adjusted for Sarnat stage of encephalopathy and Apgar score at 5 minutes; P = .02). The distribution of MRI patterns of brain injury differed among the glycemic groups (P = .03). The odds of predominant watershed or focal-multifocal injury was higher in infants with hypoglycemia (aOR, 6; 95% CI, 1.5-24.2) and labile glucose (6.6; 95% CI, 1.6-27) compared with infants with normoglycemia. Infants with labile glucose had higher odds (5.6; 95% CI, 1.1-29.3) of predominant basal ganglia or global injury compared with infants with normal blood glucose values. CONCLUSIONS: The early glycemic profile in infants with hypoxic ischemic encephalopathy is associated with specific patterns of brain injury on MRI. Further investigation is needed to explore its prognostic significance and role as a phenotype biomarker.

Perspectives from military neonatal transport: past, present, and future.

This article traces the historical development of neonatal transport, from ancient Greek mythology to the modern era, with a particular focus on the contributions of U.S. military aviation. The narrative begins with early efforts in thermoregulation through stationary incubators and progresses to the pivotal role of aerial hospitals during World War II. Post-WWII, the establishment of neonatal transport services in New York and advancements in incubator technology set the stage for further innovation. The U.S. military's involvement in neonatal transport, initiated in the 1970s, witnessed significant milestones, including the adaptation of ECMO technology for air transport. The narrative unfolds through the lens of U.S. military neonatology in the Western Pacific, particularly at Clark Air Base. The article concludes with insights into the U.S. Indo-Pacific Command's neonatal transport mission, highlighting challenges faced during the SARS-CoV-2/COVID-19 pandemic and the development of specialized infection containment transport systems.

Lipid Intake and Neurodevelopment in Preterm Infants.

Preterm infants are born before the critical period of lipid accretion and brain development that occurs during the third trimester of pregnancy. Dietary lipids serve as an important source of energy and are involved in complex processes that are essential for normal central nervous system development. In addition to traditional neurodevelopmental testing, novel quantitative magnetic resonance imaging (MRI) techniques are now available to evaluate the impact of nutritional interventions on early preterm brain development. Trials of long-chain polyunsaturated fatty acid supplementation have yielded inconsistent effects on neurodevelopmental outcomes and quantitative MRI findings. Recent studies using quantitative MRI suggest a positive impact of early lipid intake on brain volumes and white matter microstructural organization by term-equivalent age.

Using Nature to Nurture: Breast Milk Analysis and Fortification to Improve Growth and Neurodevelopmental Outcomes in Preterm Infants.

Premature infants are born prior to a critical window of rapid placental nutrient transfer and fetal growth-particularly brain development-that occurs during the third trimester of pregnancy. Subsequently, a large proportion of preterm neonates experience extrauterine growth failure and associated neurodevelopmental impairments. Human milk (maternal or donor breast milk) is the recommended source of enteral nutrition for preterm infants, but requires additional fortification of macronutrient, micronutrient, and energy content to meet the nutritional demands of the preterm infant in attempts at replicating in utero nutrient accretion and growth rates. Traditional standardized fortification practices that add a fixed amount of multicomponent fortifier based on assumed breast milk composition do not take into account the considerable variations in breast milk content or individual neonatal metabolism. Emerging methods of individualized fortification-including targeted and adjusted fortification-show promise in improving postnatal growth and neurodevelopmental outcomes in preterm infants.

Serratia Chorioamnionitis and Culture Proven Sepsis in a Preterm Neonate: A Case Report and Review of the Literature.

BACKGROUND: Serratia marcescens is a well-known cause of nosocomial infectious outbreaks in the neonatal intensive care unit, with a high mortality rate in the vulnerable preterm population. However, it is not typically associated with neonatal sepsis secondary to intrapartum vertical transmission. We present the case of a preterm male born at 25 weeks and 4 days of gestation in Okinawa, Japan with culture-proven S. marcescens chorioamnionitis and sepsis, as well as a review of the previously published literature. METHODS: We conducted a literature search utilizing MeSH indexing with the headings [chorioamnionitis], [Serratia], and [infant, newborn] limited to "humans" with a publication date range between 1950 and 2020. RESULTS: All reported cases of preterm S. marcescens chorioamnionitis occurred in coastal locations. The majority of cases resulted in spontaneous abortion, and we found no published reports of confirmed S. marcescens chorioamnionitis in conjunction with viable preterm delivery and positive neonatal cultures. In the case presented herein, S. marcescens chorioamnionitis with associated neonatal sepsis was confirmed by positive placental and blood cultures. Bacterial clearance was achieved following an antibiotic course consisting of 5 days of gentamicin and 14 days of meropenem therapy. CONCLUSIONS: S. marcescens is an uncommon cause of chorioamnionitis that can have devastating neonatal consequences, especially in the at-risk preterm population.

Early Lipid Intake Improves Cerebellar Growth in Very Low-Birth-Weight Preterm Infants.

BACKGROUND: Despite recent advances in nutrition practice in the neonatal intensive care unit, infants remain at high risk for growth restriction following preterm birth. Additionally, optimal values for macronutrient administration, especially lipid intake, have yet to be established for preterm infants in the extrauterine environment. METHODS: We studied preterm infants born at very low-birth weight (VLBW, <1500 g) and ≤32 weeks' gestation. Cumulative macronutrient (carbohydrate, lipid, protein, energy) intake in the first 2 and 4 weeks of life was compared with total and regional brain volumes on magnetic resonance imaging (MRI) obtained at term-equivalent age. Preterm infants had no structural brain injury on conventional MRI. RESULTS: In a cohort of 67 VLBW infants, cumulative lipid intake in the first 2 weeks of life was positively associated with significantly greater cerebellar volume (ß = 95.8; P = .01) after adjusting for weight gain, gestational age at birth, and postmenstrual age at MRI. Cumulative lipid (ß = 36.1, P = .01) and energy (ß = 3.1; P = .02) intake in the first 4 weeks of life were both significantly associated with greater cerebellar volume. No relationship was seen between carbohydrate or protein intake in the first month of life and cerebral volume at term-equivalent age. CONCLUSION: Early cumulative lipid intake in the first month of life is associated with significantly greater cerebellar volume by term-equivalent age in very premature infants. Our findings emphasize the importance of early, aggressive nutrition interventions to optimize cerebellar development in VLBW infants.

Positive fluid balance is associated with death and severity of brain injury in neonates with hypoxic-ischemic encephalopathy.

OBJECTIVE: To investigate the association between fluid balance during therapeutic hypothermia (TH) and severity of brain injury on magnetic resonance imaging (MRI) in neonates with hypoxic-ischemic encephalopathy (HIE). STUDY DESIGN: This is a secondary analysis of data from a prospective observational study in neonates with HIE. Daily net positive fluid balance during TH was investigated for association with the adverse primary outcome of death or moderate-to-severe brain injury on MRI using multivariable logistic regression. RESULTS: Of the 150 neonates included, 50 suffered adverse outcome and had significantly higher net positive fluid balance (53 vs. 19 ml/kg/day, p < 0.01) during first 24 hours of TH. Neonates with a net positive fluid balance (>25 ml/kg/day) at 24 hours of TH had 3.4 (95% CI 1.3-9) times higher odds of adverse outcome. CONCLUSIONS: Positive fluid balance during TH in neonates with HIE is independently associated with death or moderate-to-severe brain injury on MRI.

Wound care challenges in children and adults with spina bifida: an open-cohort study.

Skin breakdown is a frequent concern for individuals with spina bifida. We explored wound incidence in patients with spina bifida and how it varies across a person's life span and functional neurologic level. We examined the settings in which skin breakdown most commonly occurred, looking for evidence of chronic, non-healing wounds. We also sought to develop criteria to improve wound monitoring. We identified reported wound episodes in an open-cohort study over a 13-year period, examining the hospital and outpatient clinical records of spina bifida patients at Children's National Medical Center (CNMC). Current age, age at wound presentation, sex, weight, functional neurologic level, wound location, setting in which the wound was acquired, the development of a chronic wound, and presence of a shunt were recorded. Of the 376 patients in our clinical population, 123 (average age: 18.8 years, range: infancy-56 years) developed a total of 375 wounds; the majority of patients who developed one wound went on to develop one or more additional wounds, and 20 patients developed chronic wounds. Our data suggest that age bracket (adolescents), wheelchair use, and bare feet, as well as possibly obesity and reduced executive functioning, are key risk factors for wound development. These findings have led to a focused effort to increase wound education and prevention. In addition we report on our early experience using a wound care specialist to champion this initiative.