Insulin resistance prior to term age in very low birthweight infants: a prospective study.

OBJECTIVE: To explore the glucose-related hormone profile of very low birthweight (VLBW) infants and assess the association between neonatal hyperglycaemia and insulin resistance during the admission period. DESIGN: A prospective observational study-the Very Low Birth Weight Infants, Glucose and Hormonal Profiles over Time study. SETTING: A tertiary neonatal intensive care unit and four neonatal units in county hospitals in Sweden. PATIENTS: 48 infants born <1500 g (VLBW) during 2016-2019. OUTCOME MEASURES: Plasma concentrations of glucose-related hormones and proteins (C-peptide, insulin, ghrelin, glucagon-like peptide 1 (GLP-1), glucagon, leptin, resistin and proinsulin), insulin:C-peptide and proinsulin:insulin ratios, Homoeostatic Model Assessment 2 (HOMA2) and Quantitative Insulin Sensitivity Check (QUICKI) indices, measured on day of life (DOL) 7 and at postmenstrual age 36 weeks. RESULTS: Lower gestational age was significantly associated with higher glucose, C-peptide, insulin, proinsulin, leptin, ghrelin, resistin and GLP-1 concentrations, increased HOMA2 index, and decreased QUICKI index and proinsulin:insulin ratio. Hyperglycaemic infants had significantly higher glucose, C-peptide, insulin, leptin and proinsulin concentrations, and lower QUICKI index, than normoglycaemic infants. Higher glucose and proinsulin concentrations and insulin:C-peptide ratio, and lower QUICKI index on DOL 7 were significantly associated with longer duration of hyperglycaemia during the admission period. CONCLUSIONS: VLBW infants seem to have a hormone profile consistent with insulin resistance. Lower gestational age and hyperglycaemia are associated with higher concentrations of insulin resistance markers.

Prevalence and Risk Factors for Post-Discharge Feeding Problems in Children Born Extremely Preterm.

OBJECTIVES: Preterm infants have a high risk of post-discharge feeding problems, but there is a lack of population-based studies in infants born extremely preterm and little is known about underlying mechanisms. The objectives were to assess the incidence of post-discharge feeding problems and underweight in a population-based cohort of infants born extremely preterm in Sweden (EXPRESS) and identify perinatal risk factors. METHODS: Perinatal health data and prenatal/postnatal growth data was prospectively collected in the cohort. Data on clinical diagnoses related to feeding problems were obtained from the Swedish Patient Register and population prevalence data was also obtained. The main outcome was a composite of post-discharge feeding problem diagnosis and/or underweight at 2.5 years of age. RESULTS: In total, 66 children (19%) had post-discharge feeding problems diagnosed before 2 years and/or underweight at 2.5 years of age. The risk of feeding problems when compared to the general population was significantly higher, with an odds ratio (OR) of 193 (95% confidence interval (CI) 137.6-270.9). The strongest risk factors for feeding problems were the number of days on mechanical ventilation during the first 8 postnatal weeks, OR of 1.59 (CI 95% 1.29-1.98), and the Clinical Risk Index for Babies-score, OR of 1.14 (CI 95% 1.03-1.26). CONCLUSIONS: Post-discharge feeding problems and underweight are common in children born extremely preterm. The strongest perinatal risk factor for later feeding problems was early treatment with mechanical ventilation. Identifying infants at risk of post-discharge feeding problems might be useful for targeting of nutritional support.

Sodium supply from administered blood products was associated with severe intraventricular haemorrhage in extremely preterm infants.

AIM: The aim of this study was to investigate the associations between sodium supply, fluid volume, sodium imbalances and severe intraventricular haemorrhage (IVH) in extremely preterm (EPT) infants. METHODS: We used data from the EXtremely PREterm infants in Sweden Study (EXPRESS) cohort consisting of all infants born at 22 to 26 gestational weeks from 2004 to 2007 and conducted a nested case-control study. For every infant with severe IVH (grade 3 or peri-ventricular haemorrhagic infarction), one IVH-free control infant with the birthday closest to the case infant and matched for hospital, sex, gestational age and birth weight was selected (n = 70 case-control pairs). RESULTS: Total sodium supply and fluid volume were higher in infants with severe IVH compared with controls [daily total sodium supply until postnatal Day 2: mean ± SD (mmol/kg/day): 5.49 ± 2.53 vs. 3.95 ± 1.91, p = 0.009]. These differences were accounted for by sodium and fluid from transfused blood products. High plasma sodium concentrations or large sodium fluctuations were not associated with severe IVH. CONCLUSION: Our results suggest a relationship between sodium-rich transfusions of blood products and severe IVH in EPT infants. It is unclear whether this is an effect of sodium load, volume load or some other transfusion-related factor.

Mother's Own Milk and Its Relationship to Growth and Morbidity in a Population-based Cohort of Extremely Preterm Infants.

OBJECTIVES: The aim of the study was to evaluate the relationships between intake of mother's own milk (MOM), compared with intake of pasteurized donor milk (DM), and postnatal growth, incidence of retinopathy of prematurity (ROP) and bronchopulmonary dysplasia (BPD), in extremely preterm infants. METHODS: Swedish population-based cohort of surviving extremely preterm infants born 2004 to 2007. Exposure to MOM and DM was investigated from birth until 32 weeks postmenstrual age (PMA) in 453 infants. Primary outcome variables were change in z-score (Δ) from birth to 32 weeks PMA for weight, length, and head circumference (HC). Secondary outcomes were incidence of ROP and BPD. Mixed models adjusting for confounders were used to investigate the association between exposures and outcomes. RESULTS: Infants' mean gestational age (GA) was 25.4 weeks. Unadjusted, MOM (per 10 mL ·â€Škg-1 ·â€Šday-1) was associated with Δweight and ΔHC with beta estimates of 0.03 z-score units (95% CI, 0.02-0.04, P < 0.001) and 0.03 z-score units (95% CI, 0.01-0.05, P = 0.003), respectively. After adjustment for predefined confounders, the association remained significant for Δweight and ΔHC. A similar pattern was found between Δweight and each 10% increase of MOM. Unadjusted, a higher intake of MOM (mL ·â€Škg-1 ·â€Šday-1) was significantly associated to a lower probability of any ROP and severe ROP; however, these associations did not remain in the adjusted analyses. No associations were found between MOM (mL ·â€Škg-1 ·â€Šday-1) and BPD. Moreover, no associations were found between DM and growth or morbidity outcomes. CONCLUSIONS: An increased intake of MOM, as opposed to DM (and not formula feeding), was associated with improved postnatal weight gain and HC growth from birth until 32 weeks PMA in extremely preterm infants. Interventions aiming at increasing early intake of unpasteurized MOM for extremely preterm infants should be encouraged.

Amino acid infusions in umbilical artery catheters enhance protein administration in infants born at extremely low gestational age.

AIM: It is challenging to provide extremely low gestational age neonates (ELGANs) with adequate protein supply. This study aimed to investigate whether amino acid (AA) infusion in the umbilical artery catheter (UAC) in ELGANs is safe and enhances protein supply and growth. METHOD: A before and after study including infants born <27 weeks, treated in Uppsala, Sweden, during 2004-2007, compared those receiving normal saline/10% dextrose in water with those receiving AA infusion in the UAC. Data were retrieved from the Extremely Preterm Infants in Sweden Study, hospital records and the Swedish Neonatal Quality Register. Group comparisons, univariate and multivariate analyses were conducted. RESULTS: AA group (n = 41, females 39%) received on average approximately 0.3 g/kg/day more protein during the first postnatal week, compared to control group (n = 30, females 40%) (unstandardised coefficient (B) 0.26, p .001) but no difference was noted during 8-28 postnatal days. The type of infusion was not associated with growth variables. The incidence of neonatal morbidities and UAC-related thrombosis did not differ between the groups. CONCLUSION: AA infusions in the UACs in ELGANs is safe and enhances protein supply during the first postnatal week. However, this practice is not associated with growth during the first 28 postnatal days.

Association between Neonatal Intakes and Hyperglycemia, and Left Heart and Aortic Dimensions at 6.5 Years of Age in Children Born Extremely Preterm.

Survivors of extremely preterm birth (gestational age < 27 weeks) have been reported to exhibit an altered cardiovascular phenotype in childhood. The mechanisms are unknown. We investigated associations between postnatal nutritional intakes and hyperglycemia, and left heart and aortic dimensions in children born extremely preterm. Postnatal nutritional data and echocardiographic dimensions at 6.5 years of age were extracted from a sub-cohort of the Extremely Preterm Infants in Sweden Study (EXPRESS; children born extremely preterm between 2004-2007, n = 171, mean (SD) birth weight = 784 (165) grams). Associations between macronutrient intakes or number of days with hyperglycemia (blood glucose > 8 mmol/L) in the neonatal period (exposure) and left heart and aortic dimensions at follow-up (outcome) were investigated. Neonatal protein intake was not associated with the outcomes, whereas higher lipid intake was significantly associated with larger aortic root diameter (B = 0.040, p = 0.009). Higher neonatal carbohydrate intake was associated with smaller aorta annulus diameter (B = -0.016, p = 0.008). Longer exposure to neonatal hyperglycemia was associated with increased thickness of the left ventricular posterior wall (B = 0.004, p = 0.008) and interventricular septum (B = 0.004, p = 0.010). The findings in this study indicate that postnatal nutrition and hyperglycemia may play a role in some but not all long-lasting developmental adaptations of the cardiovascular system in children born extremely preterm.

Fruit Pouch Consumption and Dietary Patterns Related to BMIz at 18 Months of Age.

Concerns have been raised that an overconsumption of baby food fruit pouches among toddlers might increase the risk of childhood obesity. This study aimed to quantify the consumption of fruit pouches and other fruit containing food products and to explore potential correlations between the consumption of these products and body-mass index z-score (BMIz) at 18 months, taking other predictive factors into consideration. The study was based on 1499 children and one-month-recall food frequency questionnaires from the Swedish population-based birth cohort NorthPop. Anthropometric outcome data were retrieved from child health care records. BMIz at 18 months of age was correlated to maternal BMI and gestational weight gain and inversely correlated to fruit juice consumption and breastfeeding. BMIz at 18 months of age was not correlated to consumption of fruit pouches, sugar-sweetened beverages, whole fruit or milk cereal drink. Overweight at 18 months of age was correlated to maternal BMI and inversely correlated to breastfeeding duration. To our knowledge, this is the first study that investigates possible associations between baby food fruit pouch consumption and overweight in toddlers. We found that moderate fruit pouch consumption is not associated with excess weight at 18 months of age.

Neonatal hyperglycaemia is associated with worse neurodevelopmental outcomes in extremely preterm infants.

OBJECTIVE: To assess the associations between neonatal hyperglycaemia and insulin treatment, versus long-term neurodevelopmental outcomes in children born extremely preterm. DESIGN AND SETTING: Observational national cohort study (Extremely Preterm Infants in Sweden Study) using prospectively and retrospectively collected data. Neurodevelopmental assessment was performed at 6.5 years of age. PATIENTS: 533 infants born <27 gestational weeks during 2004-2007; 436 survivors were assessed at 6.5 years. OUTCOME MEASURES: Neurodevelopmental disability (NDD), survival without moderate to severe NDD, Wechsler Intelligence Scale for Children IV Full scale intelligence quotient (WISC-IV FSIQ) and Movement Assessment Battery for Children 2 (MABC-2) total score. RESULTS: Duration of neonatal hyperglycaemia >8 mmol/L was associated with WISC-IV scores-for each day with hyperglycaemia there was a decrease of 0.33 points (95% CI 0.03 to 0.62) in FSIQ. Neonatal hyperglycaemia >8 mmol/L occurring on 3 consecutive days was associated with lower MABC-2 scores (adjusted mean difference: -4.90; 95% CI -8.90 to -0.89). For each day with hyperglycaemia >8 mmol/L, there was a decrease of 0.55 points (95% CI 0.17 to 0.93) in MABC-2 total score. Insulin treatment was not associated with any of the outcome measures. CONCLUSION: Neonatal hyperglycaemia >8 mmol/L was associated with lower intelligence scores and worse motor outcomes at 6.5 years of age. Insulin treatment was not associated with either worsened or improved neurodevelopmental outcomes. Randomised controlled trials are needed to clarify the role of insulin in treating hyperglycaemia in extremely preterm infants.

Erythrocyte transfusions increased the risk of elevated serum ferritin in very low birthweight infants and were associated with altered longitudinal growth.

AIM: There has been a lack of population-based longitudinal data on serum ferritin in very low birthweight (VLBW) infants during hospitalisation. Our aim was to fill this gap in the knowledge and investigate risk factors for elevated serum ferritin and associations between erythrocyte transfusions and longitudinal growth. METHODS: We retrospectively reviewed longitudinal data on 126 VLBW infants treated at Umeå University Hospital, Sweden, between 2010 and 2013. RESULTS: The infants' mean gestational age and birthweight were 26.9 weeks and 899 g. Most (91%) received erythrocyte transfusions, and the majority had multiple erythrocyte transfusions. There was a significant correlation between serum ferritin and the volume of transfusions. Almost two-thirds had at least one serum ferritin measurement of more than 350 µg/L, indicating iron overload. In those with complete anthropometric data (n = 78), there was no significant effect of serum ferritin concentrations in relation to longitudinal growth, but there was a positive association between the erythrocyte transfusion dose and longitudinal growth in VLBW infants born before 25 weeks. CONCLUSION: This is the first population-based study to investigate longitudinal data on serum ferritin in VLBW infants during hospitalisation. The unexpected positive finding in the subgroup born at less than 25 weeks needs further research with a larger cohort.

Postnatal nutritional intakes and hyperglycemia as determinants of blood pressure at 6.5 years of age in children born extremely preterm.

BACKGROUND: Adverse developmental programming by early-life exposures might account for higher blood pressure (BP) in children born extremely preterm. We assessed associations between nutrition, growth and hyperglycemia early in infancy, and BP at 6.5 years of age in children born extremely preterm. METHODS: Data regarding perinatal exposures including nutrition, growth and glycemia status were collected from the Extremely Preterm Infants in Sweden Study (EXPRESS), a population-based cohort including infants born <27 gestational weeks during 2004-2007. BP measurements were performed at 6.5 years of age in a sub-cohort of 171 children (35% of the surviving children). RESULTS: Higher mean daily protein intake (+1 g/kg/day) during postnatal weeks 1-8 was associated with 0.40 (±0.18) SD higher diastolic BP. Higher mean daily carbohydrate intake (+1 g/kg/day) during the same period was associated with 0.18 (±0.05) and 0.14 (±0.04) SD higher systolic and diastolic BP, respectively. No associations were found between infant growth (weight, length) and later BP. Hyperglycemia and its duration during postnatal weeks 1-4 were associated primarily with higher diastolic BP z-scores. CONCLUSIONS: These findings emphasize the importance of modifiable early-life exposures, such as nutrition and hyperglycemia, in determining long-term outcomes in children born extremely preterm.

Early energy and protein intakes and associations with growth, BPD, and ROP in extremely preterm infants.

BACKGROUND & AIM: Extremely preterm infants face substantial neonatal morbidity. Nutrition is important to promote optimal growth and organ development in order to reduce late neonatal complications. The aim of this study was to examine the associations of early nutritional intakes on growth and risks of bronchopulmonary dysplasia (BPD) and retinopathy of prematurity (ROP) in a high-risk population. METHODS: This population-based cohort study includes infants born before 27 0/7 weeks of gestational age without severe malformations and surviving ≥10 days. Intake of energy and protein on postnatal days 4-6 and association with weight standard deviation score (WSDS) from birth to day 7, as well as intakes of energy and protein on postnatal days 4-6 and 7 to 27, respectively, and association with composite outcome of death and BPD and separate outcomes of BPD and ROP were examined, and adjusted for potential confounders. RESULTS: The cohort comprised 296 infants with a median gestational age of 25 3/7 weeks. Expressed as daily intakes, every additional 10 kcal/kg/d of energy during days 4-6 was associated with 0.08 higher WSDS on day 7 (95% CI 0.06-0.11; p < 0.001). Between days 7 and 27, every 10 kcal/kg/d increase in energy intake was associated with a reduced risk of BPD of 9% (95% CI 1-16; p = 0.029) and any grade of ROP with a reduced risk of 6% (95% CI 2-9; p = 0.005) in multivariable models. This association was statistically significant in infants with ≤10 days of mechanical ventilation. In infants with >10 days of mechanical ventilation, a combined higher intake of energy and protein was associated with a reduced risk of BPD. CONCLUSION: Early provision of energy and protein may reduce postnatal weight loss and risk of morbidity in extremely preterm infants.

Validation of the diagnosis of necrotising enterocolitis in a Swedish population-based observational study.

AIM: The definition of necrotising enterocolitis (NEC) is based on clinical and radiological signs that can be difficult to interpret. The aim of the present study was to validate the incidence of NEC in the Extremely Preterm Infants in Sweden Study (EXPRESS) METHODS: The EXPRESS study consisted of all 707 infants born before 27 + 0 gestational weeks during the years 2004-2007 in Sweden. Of these infants, 38 were recorded as having NEC of Bell stage II or higher. Hospital records were obtained for these infants. Furthermore, to identify missed cases, all infants with a sudden reduction of enteral nutrition, in the EXPRESS study were identified (n = 71). Hospital records for these infants were obtained. Thus, 108 hospital records were obtained and scored independently by two neonatologists for NEC. RESULTS: Of 38 NEC cases in the EXPRESS study, 26 were classified as NEC after validation. Four cases not recorded in the EXPRESS study were found. The incidence of NEC decreased from 6.3% to 4.3%. CONCLUSION: Validation of the incidence of NEC revealed over- and underestimation of NEC in the EXPRESS study despite carefully collected data. Similar problems may occur in other national data sets or quality registers.

Improved nutrition for extremely preterm infants - A population based observational study.

BACKGROUND AND AIMS: Extremely preterm (EPT) infants are at high risk for malnutrition due to immaturity and medical complications and they often accumulate nutritional deficits and experience growth faltering during treatment at neonatal intensive care units (NICUs). Enhanced intake of energy and protein during the first weeks of life improves weight gain and head circumference growth. The optimal nutritional strategy for these infants' health and long-term development remains unknown. Nutritional regiments have been identified as a potential area for improvement in Swedish NICUs. The aim of this study was to evaluate changes in nutritional intake over time during the first 56 postnatal days in EPT (<27 gestational weeks; n = 316) infants, who were treated in NICUs during 2004-2011 in Stockholm, using a population-based study approach. METHODS: Several different nutritional interventions were implemented over the 8-year period. Nutrition and growth data were obtained retrospectively from hospital records. All intakes of enteral and parenteral nutrients were retrieved daily during the first 28 postnatal days and on days 35, 42, 49 and 56. RESULTS: Energy intake (median) increased from 77 kcal/kg/d during the 2004-2005 period to 98 kcal/kg/d during the 2010-2011 period on days 4-6. Median protein intake increased from 2.4 g/kg/d during 2004-2005 to 3.6 g/kg/d during 2010-2011. Energy and protein intake during postnatal days 0-6 increased continuously over the 8 years and protein intake increased during all 56 postnatal days. Full enteral feeds were reached earlier and the proportion of enteral feeds during the first week was higher during 2008-2009 compared to all other years. A significant improvement in growth was primarily noted by comparing the 2004-2005 period to subsequent years. CONCLUSIONS: Neonatal nutrition improved significantly in Stockholm from 2004 to 2011. Above all, parenteral nutrition was initiated more promptly during the first week and was provided at higher quantities. However, many of the EPT infants born during the later years still did not reach the recommended macronutrient intake levels. A significant weight gain improvement was observed between 2004-2005 and 2006-2011.

Low energy intake during the first 4 weeks of life increases the risk for severe retinopathy of prematurity in extremely preterm infants.

OBJECTIVES: Poor weight gain during the first weeks of life in preterm infants is closely associated with the risk of developing the retinopathy of prematurity (ROP) and insufficient nutrition might be an important contributing factor. This study aimed to evaluate the effect of energy and macronutrient intakes during the first 4 weeks of life on the risk for severe ROP (stages 3-5). STUDY DESIGN: A population-based study including all Swedish extremely preterm infants born before 27 gestational weeks during a 3-year period. Each infant was classified according to the maximum stage of ROP in either eye as assessed prospectively until full retinal vascularisation. The detailed daily data of actual intakes of enteral and parenteral nutrition and growth data were obtained from hospital records. RESULTS: Of the included 498 infants, 172 (34.5%) had severe ROP and 96 (19.3%) were treated. Energy and macronutrient intakes were less than recommended and the infants showed severe postnatal growth failure. Higher intakes of energy, fat and carbohydrates, but not protein, were significantly associated with a lower risk of severe ROP. Adjusting for morbidity, an increased energy intake of 10 kcal/kg/day was associated with a 24% decrease in severe ROP. CONCLUSIONS: We showed that low energy intake during the first 4 weeks of life was an independent risk factor for severe ROP. This implies that the provision of adequate energy from parenteral and enteral sources during the first 4 weeks of life may be an effective method for reducing the risk of severe ROP in extremely preterm infants.

The Specificity of the WINROP Algorithm Can Be Significantly Increased by Reassessment of the WINROP Alarm.

BACKGROUND: Retinopathy of prematurity (ROP) is a sight-threatening disease affecting extremely preterm infants. The introduction of new ROP screening surveillance systems, with higher sensitivity and specificity than established ROP screening guidelines, has the potential to reduce the number of stressful eye examinations in these infants. OBJECTIVES: To improve the specificity of the WINROP (Weight, Insulin-like growth factor-I, Neonatal, ROP) surveillance system, identifying extremely preterm infants requiring treatment for ROP. METHODS: Two cohorts that had previously been subjected to WINROP analyses were included and reevaluated in this study. The weight at WINROP alarm for extremely preterm infants, born at gestational age <27 weeks, was reevaluated and by establishing 'safe' WINROP alarm weight limits, an intersample reassessment of WINROP alarm was performed. The two cohorts were as follows: (1) the Extremely Preterm Infants in Sweden Study (EXPRESS) cohort, infants born in Sweden during 2004-2007 (n = 407), and (2) extremely preterm infants in a North American cohort, born during 2006-2009 (n = 566). RESULTS: In the EXPRESS cohort, 12.5% (40/319) of the infants who previously received a WINROP alarm were now reassessed as having no alarm; the specificity of WINROP in EXPRESS increased from 23.9% (86/360) to 35.0% (126/360). In the North American cohort, 15.4% (81/526) were reassessed as having no alarm; the specificity increased from 8.5% (38/447) to 26.6% (119/447). The sensitivity persisted as 97.5% in EXPRESS (45/47) and 98.3% (117/119) in the North American cohort. CONCLUSIONS: The specificity of the WINROP surveillance system for extremely preterm infants can be significantly improved by reassessment using the weight at WINROP alarm.

Intake and macronutrient content of human milk given to extremely preterm infants.

BACKGROUND: Human milk (HM) is the preferred basis of nutrition for infants, including those born prematurely. Information on HM macronutrient content is necessary to optimize nutritional support of preterm infants. OBJECTIVES: This study aimed to describe the types and amounts of enteral feeds given to Swedish extremely preterm infants during hospitalization and to investigate the energy and macronutrient contents in HM given to these infants. METHODS: A population-based study of Swedish extremely preterm infants (n = 586) born before 27 gestational weeks was conducted. Data on ingested volumes of different milk during hospitalization and analyses of macronutrient content in HM samples were obtained from hospital records. Nutritional content of HM was determined by mid-infrared spectrophotometry analysis. RESULTS: During the first 4 weeks of life, 99% of the infants were exclusively fed HM, and at 4 weeks of life, 70% of the infants received only mother's own milk (MOM). Nutritional content in 821 MOM samples was analyzed. Protein content in MOM decreased significantly from 2.2 to 1.2 g/100 mL during the first 112 postpartum days, whereas fat and energy content were highly variable within and between MOM samples. In addition, 354 samples of donor milk were analyzed. Content of protein, fat, and energy in pooled donor milk (n = 129) was lower compared to single donor milk. CONCLUSION: Swedish extremely preterm infants receive MOM to a large extent during hospitalization. Protein, carbohydrates, and energy in MOM changed significantly with time. Weekly analyses of MOM during the first month of lactation would allow more individualized nutritional support for these vulnerable infants.

Perioperative nutrition in extremely preterm infants undergoing surgical treatment for patent ductus arteriosus is suboptimal.

AIM: To evaluate perioperative nutrition in extremely preterm infants undergoing surgery for patent ductus arteriosus (PDA). METHODS: This is a population-based study of extremely preterm infants born in Sweden during 2004-2007 and operated on for PDA. Data on perioperative nutrition were obtained from hospital records. All enteral and parenteral nutrients and blood products were used to calculate daily nutritional intakes, starting 3 days before and ending 3 days after surgery. Data are mean (95% confidence intervals). RESULTS: Study infants (n = 140) had a mean gestational age (GA) of 24.8 weeks, and mean birth weight was 723 g. Energy and macronutrient intakes were below minimal requirements before, during and after PDA surgery. On the day of surgery, energy intake was 78 (74-81) kcal/kg/day, protein 2.9 (2.7-3.2) g/kg/day, fat 2.5 (2.3-2.7) g/kg/day and carbohydrate intake 10.7 (10.2-11.2) g/kg/day. Nutrition did not vary in relation to GA, but infants operated early (0-6 days after birth) received poorer nutrition than infants operated at older age. Fluid intake was 164 (159-169) mL/kg/day, and it did not vary during the week of surgery. CONCLUSION: Perioperative nutrition in extremely preterm infants undergoing PDA surgery in Sweden is suboptimal and needs to be improved. The significance of malnutrition for outcome after PDA surgery remains unclear and requires further investigation.

WINROP identifies severe retinopathy of prematurity at an early stage in a nation-based cohort of extremely preterm infants.

OBJECTIVE: To evaluate the ability of a postnatal weight-gain algorithm (WINROP) to identify sight-threatening retinopathy of prematurity (ROP type 1) in a nation-based extremely preterm infant cohort. METHODS: This study enrolled all 707 live-born extremely preterm (gestational age [GA] <27 weeks) infants, born 2004-2007 in Sweden; the Extremely preterm Infants in Sweden Study (EXPRESS). WINROP analysis was performed retrospectively in 407 of the infants using weekly weight gain to assess the preterm infant's risk of developing ROP type 1 requiring treatment. GA, birthweight (BW), and weekly postnatal weight measurements were entered into WINROP. WINROP signals with an alarm to indicate if the preterm infant is at risk for ROP type 1. RESULTS: In this extremely preterm population, WINROP correctly identified 96% (45/47) of the infants who required treatment for ROP type 1. The median time from alarm to treatment was 9 weeks (range, 4-20 weeks). CONCLUSIONS: WINROP, an online surveillance system using weekly weight gain, identified extremely preterm infants at risk for ROP type 1 requiring treatment at an early stage and with high sensitivity in a Swedish nation-based cohort.

Nutrient intakes independently affect growth in extremely preterm infants: results from a population-based study.

AIM: To explore associations between energy and macronutrient intakes and early growth in extremely low gestational age (ELGA) infants. METHODS: Retrospective population-based study of all ELGA infants (<27 weeks) born in Sweden during 2004-2007. Detailed data on nutrition and anthropometric measurements from birth to 70 days of postnatal age were retrieved from hospital records. RESULTS: Study infants (n = 531) had a mean ± SD gestational age of 25.3 ± 1.1 weeks and a birth weight of 765 ± 170 g. Between 0 and 70 days, average daily energy and protein intakes were 120 ± 11 kcal/kg and 3.2 ± 0.4 g/kg, respectively. During this period, standard deviation scores for weight, length and head circumference decreased by 1.4, 2.3 and 0.7, respectively. Taking gestational age, baseline anthropometrics and severity of illness into account, lower energy intake correlated with lower gain in weight (r = +0.315, p < 0.001), length (r = +0.215, p < 0.001) and head circumference (r = +0.218, p < 0.001). Protein intake predicted growth in all anthropometric outcomes, and fat intake was positively associated with head circumference growth. CONCLUSION: Extremely low gestational age infants received considerably less energy and protein than recommended and showed postnatal growth failure. Nutrient intakes were independent predictors of growth even after adjusting for severity of illness. These findings suggest that optimized energy and macronutrient intakes may prevent early growth failure in these infants.