[How I explore intrauterine growth restriction]. / Comment j'explore le retard de croissance intra-utérin.

Intrauterine growth restriction (IUGR) is a common obstetrical condition (10 % of all pregnancies). Its origin is most often vascular, but it may also be a symptom of another fetal pathology (infectious, genetic, syndromic). Screening may be complicated due to the low sensitivity of the clinical examination as well as ultrasound. However, IUGR exposes the newborn to increased perinatal morbidity and mortality. In addition, various studies show that children born with low birth weight have a higher incidence of metabolic disorders in the long term. If an IUGR is discovered, an etiological development and management strategy must be carried out in a multidisciplinary manner.

Le retard de croissance intra-utérin est une pathologie obstétricale fréquente (10 %). Le plus souvent d'étiologie vasculaire, il peut cependant être le symptôme d'une pathologie fœtale autre (infectieuse, génétique, syndromique). Le dépistage peut être compliqué en raison d'une faible sensibilité, tant clinique qu'échographique. Il expose pourtant le nouveau-né à une morbi-mortalité périnatale augmentée à court terme. Par ailleurs, différentes études montrent que les enfants nés avec un faible poids présentent, à plus long terme, une incidence majorée de pathologies métaboliques. En cas de découverte d'un retard de croissance intra-utérin, une mise au point étiologique et une stratégie de prise en charge doivent être réalisées de façon multidisciplinaire.

[Newborn infants' first outpatient visit]. / Première consultation ambulatoire du nouveau-né.

The focus on outpatient follow-up of newborn infants increases as the duration of hospital stay after birth decreases. The first outpatient visit addresses the adequacy of the home transition. Appropriate feedings are checked. Sudden infant death syndrome prevention and security advices are reminded. Realisation of both neonatal dried blood screen and hearing test is confirmed, as well as planning of specific follow-up appointments. The physical exam will focus on red flags for diseases or malformations with a delayed presentation.

Le suivi ambulatoire du nouveau-né devient important en raison de la réduction progressive des séjours en maternité. Lors de cette première consultation, il convient de s'assurer du bon déroulement du retour à domicile. L'alimentation est vérifiée. Les conseils de sécurité et ceux de prévention de la mort subite du nourrisson sont rappelés. La réalisation des dépistages sanguin et auditif est contrôlée, de même que la programmation des suivis spécifiques potentiellement nécessaires. L'examen clinique recherchera les signes d'alerte des pathologies d'apparition secondaire, comme l'ictère, ou les malformations congénitales à expression tardive.

[CA, P, AND MG POSTNATAL METABOLISM AND REQUIREMENTS IN PARENTERAL AND ENTERAL NUTRITION OF PREMATURE INFANTS]. / CA, P ET MG : MÉTABOLISME POSTNATAL ET BESOINS NUTRITIONNELS CHEZ LE PRÉMATURE EN ALIMENTATION PARENTÉRALE OU ENTÉRALE.

During the last trimester of gestation, transplacental mineral transfer and fetal mineral accretion is particularly high: 2.3-3.2 mmol/kg/day (90-130 mg/kg/d) of calcium, 2.4-2.7 mmol/kg/d (65-75 mg/kg/day) of phosphorus and 0.12-0.20 mmol/kg/d (2.9-4.8 mg/kg/day) of magnesium. After birth, there is a dramatic change in bone mineral metabolism from a maximal bone deposition during fetal life to a postnatal bone turnover stimulation improving bone structure and resistance. This physiological change could partly reduce the mineral requirements, as minerals available from the remodeling activities could be recycled for bone mineralization. In addition, recent studies in preterm infants, suggest that the use of early more "aggressive" nutritional support, providing high aminoacid intakes from the first day of life, may induce a "refeeding like syndrome" suggesting that early phosphorus and electrolytes supplies are also necessary. The aim of the present paper is to review the mineral metabolism of Very Low Birth Weight (VLBW) infants during the first weeks of life at the light of the more recent studies and to revise the nutritional recommendations for mineral parenteral and enteral intakes in VLBW infants.

[How I explore and treat a neonatal renal vein thrombosis: a case report]. / Comment j'explore et traite une thrombose veineuse renale néonatale: àpropos d'un cas.

Neonatal renal vein thrombosis is a rare condition. The present case is rather unfrequent and particularly educative since it shows the complete diagnostic triad including hematuria, flank mass and thrombocytopenia. The diagnosis relies on the demonstration, by Doppler ultrasound, of an obstructed renal venous bed. The investigation is completed by a platelet count and the determination of the prothrombin time, of the activated partial thromboplastin time as well as of the concentration of fibrinogen. The screening also includes the search for a possible etiology, such as a deficiency in coagulation proteins, the presence of antiphospholipid antibodies or of a genetic mutation of one of the coagulation factors. Since there exist no evidence based guidelines for the management of the disease, we will discuss the diagnosis and treatment in relation with the published literature.

Prematurity and bone health.

Recent advances in neonatal care significantly increases survival rate in preterm and particularly in extremely low birth weight infants (ELBW infants) and nutrition is becoming one of the most challenging issue to improve short and long term health and developmental outcomes. Nutrition is also relevant for bone development and mineralization reducing the risk of osteopenia and metabolic bone disease (MBD). Osteopenia of prematurity is a multifactorial disease including predominantly nutritional but also biomechanical and environmental factors. At birth, the fetal active mineral transfer is interrupted and the preterm becomes related to the parenteral and enteral mineral supplies. On the other hand, physiological adaptation of bone to extra uterine life leads to an increase in bone resorption. This process occurring earlier in preterm than in term infants can be accompanied by an increased risk of bone fragility and fractures. Early provision of highly bioavailable mineral supplies, correction of vitamin D deficiency and the screening of serum phosphorus concentration combined to urinary mineral excretion appears to be helpful for the prevention of MBD. When available, DEXA is more sensitive than ultrasound for quantifying osteopenia in VLBW infants at the time of discharge. Catch-up of mineralization is rapidly observed during the post term period and osteopenia of prematurity seems to be a self-resolving disease although the potential long-term consequences on the attainment of peak bone mass remains uncertain.

[Early nutrition, postnatal growth retardation and outcome of VLBW infants]. / Apports nutritionnels précoces, hypotrophie acquise et devenir du prématuré

Early nutrition is an important determinant of growth, morbidity and psychomotor development in very low birth weight infants. Recent data suggest that "aggressive nutrition" providing early and high protein supply from the first hours of life improves nitrogen balance, reduces postnatal growth retardation, decreases morbidity and is positively related to psychomotor development. This paper will summarize the metabolic bases of this optimal nutrition for preterm infants.

[Evaluation of the bacteriologic quality of breast milk in a neonatology service in Belgium]. / Evaluation de la qualité bactériologique du lait maternel dans un service de néonatologie.

Many studies demonstrated that human milk is the recommended source of enteral nutrition in preterm infants providing several benefits with regards to feeding tolerance, immunity and cognitive development However, neurological immaturity and associated clinical conditions prevent them from suckling effectively. Therefore, mother's milk must be expressed, stored and transported to the neonatal unit and could be contaminated. The microbiological quality of human milk was evaluated on each donation to the neonatal intensive care unit of the University of Liege, Belgium from November 1, 2003 to January 31, 2005. In all, 5842 samples from 176 mothers were included in the study. Samples were classified according to the exclusive presence of coagulase negative Staphylococcus and their number (less or more than 104 germs per ml) or to contamination with pathogens. More than 50% of analyzed milks had to be pasteurized (46%; >104 coagulase negative Staphylococcus per ml) or to be discarded (7% pathogen contamination). The incidence of pasteurisation tends to increase during the summer, suggesting a seasonal influence. Maternal profiles were established longitudinally. Among the 60 mothers whose at least one sample had pathogen contamination, 27% had a contamination occurring only during a few days, but 73% had more than 50% of their samples discarded. This study suggest the need to promote the use and the financial support of intrahospital human milk bank units to support the safe use of raw and pasteurised human milk in preterm infants.

[Prader-Willi syndrome: specific management by a multidisciplinary team]. / Le syndrome de Prader Willi: intérêt d'une prise en charge pluridisciplinaire.

Prader Willi syndrome can be viewed as a physiopathological model of obesity. Such patients deserve specific management, preferably in a multidisciplinary setting. The paper reports on 6 patients followed in the paediatric endocrine service at the University of Liege.

Software and scan acquisition technique-related discrepancies in bone mineral assessment using dual-energy X-ray absorptiometry in neonates.

AIM: In adults, whole-body mineralization assessment by dual-energy X-ray absorptiometry can be affected by the densitometer and/or the software used. As there are no published data on neonates, the aim of this study was to evaluate the magnitude of such effects in growing preterm infants. METHODS: We analysed the absorptiometry results obtained from 44 preterm infants scanned at discharge and again 6 wk later using densitometers from the same manufacturer equipped with "Pediatric" (Group A, n = 24) or with "Infant" (Group B, n = 20) packages. Results of bone mineral content assessment were compared using an unpaired t-test and a linear regression analysis. RESULTS: At the time of the first absorptiometry (body weight = 2119 +/- 144 g, n = 44), the bone mineral content was three times lower in Group A (10 +/- 3 g) than in Group B (29 +/- 4 g) (p < 0.001). Subsequently, on the second absorptiometry (body weight = 4037 +/- 236 g, n = 44) such significant differences in bone mineral content (A: 65 +/- 19 g, B: 66 +/- 9 g, p = 0.85) were no longer in evidence. The differences in bone mineral content were related to differences in analysis algorithms between the two programs, which can lead to an overestimation of bone mineral content accretion when two successive measurements are made using the "Pediatric"package. CONCLUSION: Considering that significant differences in bone mineral assessment may depend upon which program is used, data previously collected in low birthweight infants using the "Pediatric" package should be analysed with caution. Data obtained using the "Pediatric" and "Infant" packages are not directly comparable. Careful validation studies of future densitometers and programs are required before their use in clinical paediatric studies.

Body composition in preterm infants fed standard term or enriched formula after hospital discharge.

BACKGROUND: Most preterm infants are still preterm and have a low birth weight when they are discharged from the hospital. An important issue is whether the long-term consequences of early growth restriction can be diminished by nutritional intervention in preterm infants after discharge from the hospital. AIM: To evaluate differences in growth and in weight gain composition of preterm infants fed standard term formula (SF) or enriched formula (PDF) after discharge from hospital during the first 2 months of life. METHODS: Thirty-three healthy preterm infants, birth weight < 1750 g at gestational age < 35 weeks, were randomised to SF or PDF at the time of discharge from hospital. Anthropometric variables were studied longitudinally and body composition was measured using dual energy x-ray absorptiometry (DEXA) twice, before hospital discharge and two months later. Weight gain composition was calculated as the difference between the two determinations. RESULTS: Seventeen infants were fed SF and 16 PDF. Anthropometric variables and whole body composition were similar at birth, at the start of the nutritional study (mean age 45 days), and at the end of the study 2 months later. Over the whole study period, weight gain and weight gain composition were similar in the two groups. Sex did not appear to influence weight gain and weight gain composition. In infants with growth restriction at discharge there was a significant reduction of weight gain, fat mass gain, and bone mineral content deposition independently of the formula provided. CONCLUSIONS: There is no immediate effect on preterm infants of a nutrient enriched formula compared with a standard formula on growth, weight gain, or weight gain composition.

Crecimiento, composición del incremento de peso y la absorción de minerales en recién nacidos a término alimentario con una nueva fórmula experimental conteniendo un hidrolizado de proteínas B-Palmitato y prebióticos / Growth, weight gain composition and mineral accretion in term infants fed a new experimental formula containing hydrolysed protein, B-palmitate and prebiotics

Objetivo: La leche materna es la alimentación de referencia para neonatos. Las fórmulas de leche con propiedades funcionales similares a la leche materna deberían ser programadas de modo que garanticen que el desarrollo del crecimiento y de los parámetros metabólicos conseguidos en los lactantes alimentados con fórmulas artificiales, son similares a los de los lactantes alimentados con lactancia materna. En el presente estudio sobre el crecimiento, se analizó en 14 recién nacidos a término alimentados con una fórmula nueva (FN) la composición del incremento de peso, la absorción de minerales y el desarrollo de la flora intestinal. Se compararon los resultados con los datos de los lactantes alimentados con lactancia materna (LM) y con lactantes alimentados con una fórmula estándar (FE).Metodología: Recién nacidos a término alimentados con fórmula reciben NF desde el nacimiento hasta la edad de dos meses. Las sustancias prebióticas en la NF fueron galacto y fructo-oligosacáridos (cantidad total: 0,4 g/100 ml). La NF contiene proteína de trigo parcialmente hidrolizada y B-palmitato (total ácido palmítico 0,6 g/100 ml; 41 por ciento en posición sn-2). La composición de la NF es idéntica a la de Omneo, excepto por la cantidad total de sustancias prebióticas. La tolerancia clínica, la ingesta de fórmula y las muestras de heces fueron obtenidas antes de la salida de la maternidad y a la edad de 3, 6 y 9 semanas. Se efectuaron análisis completos de la composición corporal mediante DEXA después del nacimiento, durante los primeros días de vida y a la edad de 2 meses. Se analizó el porcentaje de bifidobacterias existente en heces mediante "hibridación fluorescente in situ (FISH)".Resultados: 15 recién nacidos fueron enrolados en el estudio, uno de los recién nacidos se retiró debido a reflujo gastroesofágico. Las características antropométricas en el momento del nacimiento fueron: peso corporal 3318 ñ 406 g, longitud 50,0 ñ 1,7 cm, circunferencia craneal: 34,6 ñ 1,3 cm. Los datos de la investigación clínica obtenidos el día 3 ñ 1, día 25 ñ 4, día 45 ñ 4 y día 68 ñ 4 indican un volumen de ingesta y una evolución del peso corporal adecuados y excelente tolerancia a la alimentación. La media del incremento de peso corporal durante el período del estudio fue de 7,8 ñ 1,4 g/kg/d, incremento en la longitud: 0,91 ñ 0,19 cm/sem, circunferencia craneal: 0, 62 ñ 0, 09 cm/sem. La composición del incremento de peso fue 61 por ciento de masa corporal, 37,2 por ciento de masa grasa y 1,5 por ciento de masa mineral ósea. Por lo tanto, entre los días 3 ñ 1 y 68 + 4: la masa de grasa se incrementó de 12,6 a 22,6 por ciento, el contenido de mineral óseo de 56,7 a 90,9 g, y el área ósea de 295 a 430 crn2 mientras que el índice de densidad volumétrica mineral del hueso experimentó un descenso de 11,1 a 10,1. El porcentaje medio de bífidobacteria en las muestras fecales recogidas a la edad de 3 ñ 1 días fue de 21 por ciento. A la edad de 25Iñ 4, 45 ñ 4 y 68 ñ 4 días esta proporción fue 53, 56 y 50 por ciento indicando un rápido efecto bifidogénico de la NF y la capacidad de la NF para mantener una flora bifidobacterial estable. Conclusiones: El crecimiento y la calidad del crecimiento de los lactantes alimentados con la fórmula nueva (FN) fueron similares a los alimentados con lactancia materna (LM) y a los alimentados con fórmulas de inicio estándares (FE). El ligero descenso en la densidad volumétrica del hueso, debido al incremento en el área ósea superior al incremento en la densidad mineral del hueso durante este período de rápido crecimiento, fue similar a nuestros resultados previos en lactantes alimentados con LM y FE (EJP en prensa). La utilización de prebióticos en FN, dio como resultado un incremento rápido y significativo del porcentaje de bifidobacteria endógena y la capacidad de mantener una flora intestinal estable durante los primeros meses de vida (AU)

Evaluation of weight gain composition during the first 2 months of life in breast- and formula-fed term infants using dual energy X-ray absorptiometry.

Healthy term breast- and adapted formula-fed infants show similar weight gain and weight gain composition during the first months of life.

Weight gain composition in preterm infants with dual energy X-ray absorptiometry.

Whole body composition was investigated using dual energy x-ray absorptiometry in 54 healthy preterm infants, birth weight < 1750 g, who were fed fortified human milk (n = 20) and preterm formula (n = 34) when full enteral feeding was attained and then again 3 wk later at around the time of discharge. Weight gain composition was calculated from the difference between the earlier and later measurement. The minimal detectable changes in whole body composition over time according to the variance of the population (within groups of 20 infants) and the minimal detectable changes according to the dietary intervention (between two groups of 20 infants) were determined at 5% significance and 80% power. Whole body composition was similar in the two groups at the initial measurement, but all the measured variables differed at the time of the second measurement. Formula-fed infants showed a greater weight gain (19.9 +/- 3.2 versus 15.9 +/- 2.2 g.kg(-1).d(-1), p < 0.05), fat mass deposition (5.1 +/- 1.9 versus 3.3 +/- 1.3 g.kg(-1).d(-1), p < 0.05), bone mineral content gain (289 +/- 99 versus 214 +/- 64 mg.kg(-1).d(-1), p < 0.05), and increase in bone area (1.6 +/- 0.4 versus 1.3 +/- 0.3 cm(2).kg(-1).d(-1), p < 0.05) compared with the fortified human milk group. From these data, a minimal increase from the first measurement of 111 g lean body mass, 68 g fat mass, and 3. 1 g bone mineral content is needed to be detectable in a longitudinal study that includes 20 infants. For significance between two groups of 20 infants around the time of discharge, dietary intervention needs to achieve minimal differences of 160 g lean body mass, 86 g fat mass, and 4.1 g bone mineral content. With respect to weight gain composition, the minimal differences required to reach significance are 2.1 g.kg(-1).d(-1) for gain in lean body mass, 1.2 g.kg(-1).d(-1) for gain in fat mass, and 76 mg.kg(-1). d(-1) for gain in bone mineral content. We conclude that dual energy x-ray absorptiometry allows evaluation of the effects of dietary intervention on whole body and weight gain composition in preterm infants during the first weeks of life.

Nutritional assessment in preterm infants with special reference to body composition.

In recent years, improvements in care have significantly improved survival in preterm and, particularily, the very low birth weight infant (VLBW). While immediate survival can be directly related to pulmonary maturity, several studies stress the importance of timely and adequate nutrition in these high-risk infants on a short- and long-term [1]. Yet, nutritional support remains a very controversial issue in these high-risk infants. Early provision of adequate intakes may be limited by clinical instability and immaturity. At the same time, nutritional requirements and methods of nutritional assessment are not well defined. The aim of this paper is to outline some of the methods used during nutritional assessment in preterm infants with special reference to the measurement of body composition.

Bone mineral metabolism in the micropremie.

Environmental factors, nutritional supplies, hormonal status, diseases, and treatments appear to affect postnatal skeletal growth and mineralization in VLBW infants. Compared with their term counterparts, ELBW infants are at risk of postnatal growth deficiency and osteopenia at the time of hospital discharge. From recent data, DXA is becoming one of the reference techniques to evaluate mineral status, whole-body composition, and effects of dietary manipulations on weight gain composition and mineral accretion in preterm infants. Weight gain and length increases need to be evaluated carefully during the first weeks of life, in the intensive care unit and out of it, in the step down unit. Nutritional survey is required to improve the nutritional supply and to maximize linear growth. As the critical epoch of growth extends, during the first weeks or months after discharge, follow-up and nutritional support need to be provided during the first years to promote early catch-up growth and mineralization. Further studies need to determine precisely the most optimal feeding regimen during this period but also need to evaluate the long-term implications of such a policy on stature, peak bone mass, and general health at adulthood.

Effect of fortification on the osmolality of human milk.

AIM: To evaluate the effect of fortification on the osmolality of human milk. METHODS: The osmolality of 47 samples of human milk was determined at baseline, just after, and 24 hours after supplementation with five different human milk fortifiers (HMF) at 4 degrees C. RESULTS: Ten minutes after HMF supplementation the osmolality of human milk was significantly higher than the sum of the respective values of HMF dissolved in water and human milk, measured separately at baseline (p<0.0001), with the exception of the HMF containing only proteins. After 24 hours a further increase in osmolality was observed. Linear regression analysis showed that total dextrin content (r=0.84) was the main determinant of the increase. CONCLUSIONS: Human milk and HMF interact to induce a rapid increase in osmolality higher than would be expected from composition alone. This rise could be explained by the amylase activity of human milk, inducing hydrolysis of the dextrin content of HMF, leading to small osmotically active molecules of oligosaccharides. The high osmolality of fortified human milk should be considered in the nutritional management of preterm infants.

[Surveillance of the very-low birthweight infant: growth and nutrition]. / Surveillance de l'ancien prématuré: croissance et nutrition.

In very low birth weight (VLBW) infants careful growth and nutritional supervision are necessary in order to reduce the incidence of persistent growth retardation after 2 to 3 years of age. Recently, post-discharge formulas with higher protein, energy and mineral content has been developed with the aim to promote catch up growth and mineral accretion during the first months of life. Based upon the most recent nutritional and growth data, the authors propose guidelines for the nutrition and growth follow-up of VLBW infants after discharge from the neonatal unit.

Reference values of body composition obtained by dual energy X-ray absorptiometry in preterm and term neonates.

BACKGROUND: As previously reported, dual-energy x-ray absorptiometry provides reliable and accurate values for bone mineralization in piglets and infants, but overestimates fat content in small infants. The purpose of the current study was to determine an appropriate equation of correction for fat mass measurement and to establish reference values of body composition of preterm and term neonates. METHODS: Fat mass and chemical whole-body fat content were evaluated by dual-energy x-ray absorptiometry in eight piglets with a body weight between 1408 and 5151 g. The results were combined with previous data obtained in 13 piglets, and two correction equations were determined according to fat mass content. Close to birth, 106 healthy appropriate-for-gestational-age preterm and term infants were scanned by dual-energy x-ray absorptiometry to determine bone mineral content, bone area, and fat mass. Fat mass content determined by dual-energy x-ray absorptiometry was corrected using the equations obtained in piglets after which lean body mass was recalculated. RESULTS: Multivariate analysis showed that dual-energy x-ray absorptiometry body weight was the best predictor of bone mineral content (r2 = 0.94), bone area (r2 = 0.95), lean body mass (r2 = 0.98), and fat mass (r2 = 0.84). Gender was an additional significant independent variable for fat mass and lean body mass. Body weight related curves of percentiles for bone mineral content, bone area, fat mass, and lean body mass, were constructed. In vivo dual-energy x-ray absorptiometry values of fat mass and calcium content estimated from bone mineral content were in accordance with previously reported whole-body carcass reference values in preterm and term neonates. CONCLUSION: Normative data of dual-energy x-ray absorptiometry body composition for healthy preterm and term infants are provided and can therefore be used in research and in clinical practice.