Effects of biologic and experiential conditions on the pattern of growth in weight of premature and full-term infants.

In this exploratory study we examined the contribution of biologic and experiential conditions to the pattern of growth in weight for premature and full-term infants. The three components of the pattern were: (a) the infant's weight level; (b) the linear growth rate; and (c) the quadratic growth rate. Biologic conditions were maturity at birth and gender. Experiential conditions included variables in the mother's caregiving and the infant's feeding behavior, nutrient intake, and acuity of illness. At 1, 4, 8, and 12 months, premature infants (n = 61) weighed significantly less than full-term infants (n = 53), but neither linear nor quadratic rates of weight gain were significantly different from the rates for the full-term infants. Multilevel analytic models showed that female gender significantly affected weight level and linear and quadratic growth rates. Negative affect and behavior in both the mother and the infant significantly increased the linear rate of weight gain. The interaction of several experiential conditions with the two biologic conditions, birth maturity and gender, affected growth outcomes. Further exploration of the model with a larger sample is indicated to enable simultaneous testing of biologic and experiential conditions.

The effects of prescribed versus ad libitum feedings and formula caloric density on premature infant dietary intake and weight gain.

BACKGROUND: Although feedings that are organized on an ad lib basis (i.e., in response to infant cues of hunger and of satiation) could enhance an infant's self-regulatory capacities for feeding, ad lib feeding of fully nipple-fed premature infants in a special care nursery has not been examined. OBJECTIVE: To study whether the caloric and protein intake and weight change of fully nipple-fed preterm infants differed by the feeding regimen (prescribed or ad lib) and by the caloric density of the formula (20- or 24-kcalories per ounce). METHOD: The 78 infants who participated in the study were randomized to prescribed or ad lib feeding regimens and, within each regimen, were further randomized to receive either 20-calorie or 24-kcalorie per ounce formula. Dietary intake (volume/kg, caloric intake/kg) and weight change (grams/kg gained or lost) were assessed for each of the 5 study days. Multivariate data analysis was used to examine the effects of feeding regimen and caloric density on dietary intake and weight change, controlling biologic variables (infant gender, race, lung disease diagnosis, treatment with supplemental oxygen, gestational age and weight at birth, and weight on the day prior to full nipple-feeding). RESULTS: Overall, the ad lib feeding regimen had a negative effect on volume intake and caloric intake. Weight gain was influenced by caloric intake, but not by feeding regimen or the caloric density of the diet. With increased full nipple-feeding experience, caloric intake of ad lib feeders approached that of the infants fed on the prescribed regimen. CONCLUSIONS: Development of self-regulatory capacities through ad lib feeding experience was indicated by infant regulation of the volume of intake by the caloric density of the formula, an unexpected finding. Furthermore, the approach of the caloric intake of infants on the ad lib regimen to that of infants on the prescribed regimen suggests they had gained skill in regulating intake with experience. Whether or not the trend for similar intakes would continue beyond 5 days is a question for further study.

Transition time to full nipple feeding for premature infants with a history of lung disease.

OBJECTIVE: To (a) explore the contribution of infant, environmental, and historical factors to the number of days from initiation to achievement of full nipple feeding (transition time) for premature infants with a history of lung disease; (b) examine differences in the contribution of infant and environmental factors to transition time made by historical era, either earlier (in the 1980s) or later (in the 1990s); and (c) compare, within eras, the contribution to transition time of infant and environmental factors for infants with each lung diagnosis, respiratory distress syndrome (RDS) without bronchopulmonary dysplasia (BPD) or BPD. DESIGN: Data were collected at two midwestern hospitals from the records of premature infants with a diagnosis of either RDS without BPD or BPD. The influence on transition time of infant, environmental and historical factors was assessed with the Cox proportional hazards model. This analytic model, a form of regression analysis, also was used to explore how era influenced the contribution to transition time of infant and environmental factors. Finally, the contribution to transition time of infant and environmental factors was examined within diagnostic group for each era. SAMPLE: The hospital records audited were for infants who were 32 weeks gestational age or less with weight appropriate for gestational age. The number in each diagnostic group for each era was (a) BPD--Early, n = 35; (b) RDS--Early, n = 21; (c) BPD--Late, n = 21; and (d) RDS--Late, n = 15). RESULTS: All three types of factors (infant, environmental, and historical) contributed significantly (p < .05) to shortening or lengthening transition time. A diagnosis of BPD lengthened transition time only in the early era. Across both eras, the number of days on tube feedings significantly lengthened transition time, and the older the infant in postconceptional age (PCA) at initiation of nipple feeding, the shorter the transition time. CONCLUSION: The contribution of infant, environmental, and historical factors to transition time confirmed the basic structure of the theoretical model of transition time for premature infants with a history of lung disease. The influence of era on the contributions to transition time of infant and environmental factors suggests that care policy and practice have shortened the transition time. Although the current findings support the basic structure of the theoretical model for infants with either RDS or BPD, the marginally significant (p < .10) shortening effect of PCA on transition time for infants with BPD in both eras suggests that advancement to full nipple feeding may be limited by neurodevelopmental capacities, including respiratory control. How these capacities can be supported for advancement to full nipple feeding is a challenge for nursing practice and research.

Growth status in children with cystic fibrosis based on the National Cystic Fibrosis Patient Registry data: evaluation of various criteria used to identify malnutrition.

OBJECTIVES: The objectives of this study were to determine growth status and to identify malnutrition with various anthropometric indicators in children with cystic fibrosis (CF) based on cross-sectional analysis of the 1993 National CF Patient Registry data. METHODS: Heights and weights of 13,116 children with CF were evaluated with percentile, percent of reference median, Z-score, and percent ideal weight-for-height based on National Center for Health Statistics/Centers for Disease Control growth references. Malnutrition was defined by four criteria: (1) height-for-age <5th percentile ("stunting") or weight-for-age <5th percentile ("wasting") (2) height-for-age <90% of reference median or weight-for-age <80% of reference median, (3) height-for-age <5th percentile or percent ideal weight-for-height <85%, and (4) height-for-age <90% of reference median or weight-for-height <85% of reference median. RESULTS: Mean and median height- and weight-for-age were found to be at the 30th and 20th percentiles in children with CF. Malnutrition (height- or weight-for-age <5th percentile) was particularly pronounced in infants (47%) and adolescents (34%) and patients with newly diagnosed CF (44%). A significant sex difference (p < 0.01) in the occurrence of stunting (height-for-age <5th percentile) was observed during adolescence: boys 11 to 14 years of age showed lower occurrence of stunting (19%) compared with girls (29%), whereas the opposite trend was observed at 15 to 18 years (34% in male patients vs 28% in female patients). CONCLUSION: Twenty percent of all children in the 1993 National CF Patient Registry were <5th percentile for height- or weight-for-age. A significant discrepancy was found when different criteria were used to distinguish "stunting" versus "wasting" in malnourished children with CF.

Oral supplementation with a high-fat, high-energy product improves nutritional status and alters serum lipids in patients with cystic fibrosis.

OBJECTIVE: To assess the tolerance and acceptability of a nutrition supplement in patients with cystic fibrosis (CF), to monitor changes in dietary intake, and to evaluate nutritional status. DESIGN: Subjects were their own controls for this 3-month, prospective, open study. Acceptability and tolerance questionnaires and 3-day food records were completed at baseline and monthly intervals. Compliance and nutritional status were also assessed. SETTING: This study was conducted at the University of Wisconsin Hospital and Clinics Cystic Fibrosis Center, Madison. SUBJECTS: Patients with CF older than 4 years of age were recruited during clinic or hospital visits if they met specific weight or growth criteria (n = 19). INTERVENTION: Subjects were asked to consume the supplement at a maximum of 30% their estimated daily energy requirements. MAIN OUTCOME MEASURES: Responses to acceptability ratings of and tolerance questions about the supplement were obtained along with anthropometric data and biochemical measurements of serum albumin, plasma retinol, alpha-tocopherol, and fatty acid levels. STATISTICAL ANALYSES PERFORMED: Data were analyzed using Minitab and Statistical Analysis Software. Paired and unpaired t tests and nonparametric sign tests were used, as well as regression and Pearson correlations. A significance level of .05 was used for all tests. RESULTS: All subjects tolerated the supplement, although 12 reported mild symptoms of fullness, nausea, and/or bloating, which were resolved when intake was distributed throughout the day. Mean compliance was 69% of recommended intake. Weight gain in children was strongly correlated with compliance (r = .98). Linoleic acid intake increased significantly (P = .0003) as did plasma linoleic acid in the phospholipid fraction (P = .03). CONCLUSION: The supplement studied would be a beneficial addition to the supplementation choices available to patients with CF.

Nipple feeding for preterm infants with bronchopulmonary dysplasia.

OBJECTIVE: To examine the influence of an infant's physical condition on nipple-feeding practices and the contribution of the infant's age at complete nipple feeding to dietary intake and somatic growth outcomes. DESIGN: A retrospective, correlational study. SETTING: Two Level III nurseries. PARTICIPANTS: Records of 55 preterm infants with bronchopulmonary dysplasia. MAIN OUTCOME MEASURES: The infant's intake of kcal/kg on Day 1 of complete nipple feeding and the weight gain per day between complete nipple feeding and discharge. RESULTS: Gestational age and days on mechanical ventilation, continuous positive airway pressure, or supplementary oxygen influenced age at start and at completion of nipple feeding (p < .05). The infant's weight when nipple feeding was introduced was the primary determinant of age at introduction of nipple feeding (B = .50, p < .001). The physical condition variables did not influence the transition time from introduction of nipple feeding to complete nipple feeding. Neither the physical condition variables nor the feeding practice variables contributed to caloric intake. Weight gain between the time of complete nipple feeding and hospital discharge was less for infants who were on supplementary oxygen longer and who were older when completely nipple fed (p < .01).

Nutritional status of infants with cystic fibrosis associated with early diagnosis and intervention.

The purpose of this study was to characterize the nutritional status of infants diagnosed with cystic fibrosis (CF) through neonatal screening and to determine if they would achieve normal nutrition when managed with early intervention. In addition, nutrient intake was assessed to determine energy and macronutrient-consumption patterns. Evaluation of growth revealed that normal patterns could be achieved with mean energy intake values at ages 6 and 12 mo of 481 and 426 kJ/kg body wt (115 and 102 kcal/kg body wt), respectively. Biochemical assessment demonstrated low alpha-tocopherol and linoleic acid values at diagnosis in the majority of infants whereas one-third had abnormal indices of protein nutriture. Essential fatty acid deficiency was also demonstrated at diagnosis by abnormal triene-tetraene ratio values in 27% of screened infants. With predigested formula and dietary supplementation, there was improvement in all indices of nutritional status and only a low percentage of patients showed mild biochemical abnormalities at age 12 mo.

Nutritional assessment of infants with cystic fibrosis diagnosed through screening.

Presymptomatic infants diagnosed through neonatal screening for cystic fibrosis can have biochemical evidence of malnutrition. With aggressive dietary management and treatment with pancreatic enzymes, normal biochemical indices of nutrition can be achieved at 12 months of life in most cases. Males with cystic fibrosis appear to be more at risk than females for abnormal growth and biochemical indices of nutrition in the first year of life. This may be related to the observed decrease in fat intake when compared to females. Males, especially, should be carefully observed for development of nutritional abnormalities based on this data. Careful attention should be paid to vitamin E and essential fatty acid status in all CF infants. The numbers in this study are small and the long-term consequences of early nutritional intervention await the conclusion of the randomized, controlled study on-going in Wisconsin.

Parental issues in feeding young children with bronchopulmonary dysplasia.

This study examined the feeding issues that parents of 11 children with bronchopulmonary dysplasia (BPD) identified and explored the informational bases or criteria for decisions to initiate, continue, and/or terminate the feeding. An oral feeding by the parents was videotaped and replayed to assist in interviewing the parents regarding the decisions they had made during the feeding. Six types of feeding issues were identified. The smoothness or amenability of the child's feeding behavior was most frequently expressed as important, and about half of the parents mentioned the child's dietary intake as an issue. Most parents consistently tried to maintain the child's eating and to achieve a predetermined amount of nutritional intake. Over half the parents were concerned about adequacy of the child's nutrition, and many were concerned about their child's acceptance of or resistance to food. Parents did not express concern about their child's development but were concerned about their child's somatic growth. Parents' concern about feeding behaviors requires joint problem-solving by nurses and parents. Whether use of decision criteria that refer to the child's behavior rather than a predetermined amount of food is possible for parents and likely to contribute to reduced vomiting and resistive behavior and increased dietary intake needs further study.

Predigested formula for infants with cystic fibrosis.

The object of this study was to assess the growth rates of patients with cystic fibrosis fed various diets and test the hypothesis that the weight of infants could be normalized by 1 year of age if they were placed on predigested formula before age 6 months. A group of 19 newly diagnosed patients placed on Pregestimil were compared with a group who were fed standard formula. At 1 year of age, the Pregestimil group showed significantly greater length and weight and a twofold higher average weight percentile. Growth velocity determined for the period between diagnosis and 12 months of age was better (p less than .001) for babies raised on Pregestimil (556 compared with 423 gm/month). Using weight percentile as the major growth index and values less than the fifth percentile as abnormal at age 12 months, we found that all 19 babies were normal in the group fed Pregestimil, whereas nine were below the fifth percentile in the group fed regular formula (p = .0006).

The role of diet in managing diabetes in children.

The steps used to construct an appropriate food plan for the diabetic child and to educate the patient and his family in the goals and implementation of the plan are outlined. Factors that should be considered in constructing a flexible and workable plan include age, family situation, activity level, degree of motivation, extent of knowledge, and dietary history.