Single-Center Experience on Growth in Infants Born With End-Stage Kidney Disease.

OBJECTIVES: Children with chronic kidney disease display poor growth that impacts health outcomes; data on infants with severe congenital anomalies of the kidney and urinary tract (CAKUT) are limited. We examined growth patterns in infants with CAKUT requiring dialysis in the first 30 days. METHODS: This study evaluated infants with severe CAKUT from 2014 to 2018 surviving past 30 days. Somatic growth parameters as per standard infant curves and nutritional information were recorded. RESULTS: Twenty four infants met inclusion criteria. Seventeen infants received dialysis, demonstrating somatic growth disruption most profound at a 1-2 months postnatal age. Growth trends were improved compared to infants with CAKUT who did not require dialysis. Linear growth failed to normalize by 1 year of age. CONCLUSIONS: Infants with severe CAKUT are at high risk for early growth failure. Understanding of this deficit and impacts of early dialysis on growth and long-term outcomes are needed to identify targeted nutritional strategies.

Childhood obesity and adverse cardiometabolic risk in large for gestational age infants and potential early preventive strategies: a narrative review.

Accumulating evidence indicates that obesity and cardiometabolic risks become established early in life due to developmental programming and infants born as large for gestational age (LGA) are particularly at risk. This review summarizes the recent literature connecting LGA infants and early childhood obesity and cardiometabolic risk and explores potential preventive interventions in early infancy. With the rising obesity rates in women of childbearing age, the LGA birth rate is about 10%. Recent literature continues to support the higher rates of obesity in LGA infants. However, there is a knowledge gap for their lifetime risk for adverse cardiometabolic outcomes. Potential factors that may modify the risk in early infancy include catch-down early postnatal growth, reduction in body fat growth trajectory, longer breastfeeding duration, and presence of a healthy gut microbiome. The early postnatal period may be a critical window of opportunity for active interventions to mitigate or prevent obesity and potential adverse metabolic consequences in later life. A variety of promising candidate biomarkers for the early identification of metabolic alterations in LGA infants is also discussed. IMPACT: LGA infants are the greatest risk category for future obesity, especially if they experience rapid postnatal growth during infancy. Potential risk modifying secondary prevention strategies in early infancy in LGA infants include catch-down early postnatal growth, reduction in body fat growth trajectory, longer breastfeeding duration, and presence of a healthy gut microbiome. LGA infants may be potential low-hanging fruit targets for early preventive interventions in the fight against childhood obesity.

Body Composition of Infants With Congenital Gastroschisis.

ABSTRACT: Infants born with congenital gastroschisis are at risk for intrauterine growth restriction, small for gestational size at birth, and growth failure during the newborn period despite advanced care. Body composition provides a more complete picture of proportional growth than weight and length alone. Fat-free mass (FFM) represents organ growth, and in preterm infants without gastroschisis, improved FFM deposition is associated with improved neurodevelopmental outcomes. There is limited literature regarding the body composition of infants with gastroschisis. This case series describes the body composition of 10 infants with gastroschisis.

Adaptation of Essential Care for Every Baby educational program to improve infant outcomes in the context of Zika.

BACKGROUND: The outbreak and ongoing transmission of Zika virus provided an opportunity to strengthen essential newborn care and early childhood development systems through collaboration with the US Agency for International Development Applying Science to Strengthen and Improve Systems (USAID ASSIST). The objective was to create a system of sustainable training dissemination which improves newborn care-related quality indicators in the context of Zika. METHODS: From 2018-19, USAID ASSIST supported a series of technical assistance visits by the American Academy of Pediatrics (AAP) in four Caribbean countries to strengthen the clinical capacity in care of children potentially affected by Zika through dissemination of Essential Care for Every Baby (ECEB), teaching QI methodology, coaching visits, and development of clinical care guidelines. ECEB was adapted to emphasize physical exam findings related to Zika. The first series of workshops were facilitated by AAP technical advisors and the second series were facilitated by the newly trained local champions. Quality of care was monitored with performance indicators at 134 health facilities. RESULTS: A repeated measures (pre-post) ANOVA was conducted, revealing significant pre-post knowledge gains [F(1) = 197.9, p < 0.001] on knowledge check scores. Certain performance indicators related to ECEB practices demonstrated significant changes and midline shift on the run chart in four countries. CONCLUSION: ECEB can be adapted to incorporate important local practices, causes of neonatal morbidity and mortality, and differing healthcare system structures, which, as one part of a larger technical assistance package, leads to improved performance of health systems.

Enhancing Interpretation of One-Time Body Composition Measurement at Near-Term Gestation in Preterm Infants: An Exploratory Study.

In preterm infants, longitudinal growth patterns have a stronger association with clinical outcomes than cross-sectional metrics. For qualitative growth, a one-time body composition measurement at near term is common, and here we explore the potential use of a novel estimated longitudinal body composition metric (adjusted fat-free mass deficit) using birth anthropometrics. KEY POINTS: · Longitudinal growth patterns are better linked with clinical outcomes in preterm infants.. · Body composition is increasingly used to assess the quality of postnatal growth in preterm infants.. · Single body composition at term adjusted using birth weight may be better predictive for outcomes..

Quality Improvement Efforts Reduce Incidence of Surgical Necrotizing Enterocolitis and Related Deaths.

OBJECTIVE: The aim of this study was to determine whether a regional quality improvement (QI) initiative decreased incidence and severity of surgical necrotizing enterocolitis (NEC) in very low birth weight (VLBW) infants. STUDY DESIGN: A retrospective review of all VLBW infants who received care at one of the three hospitals involved in a NEC QI initiative from 2011 to 2016. Primary outcome was the number of surgical NEC cases per year. Secondary outcomes included associated outcomes and mortality. RESULTS: Sixty-three infants with either a diagnosis of Stage III NEC (n = 40) or spontaneous intestinal perforation (SIP) (n = 23) were included. The incidence of medical and surgical NEC and the mortality rate of infants with surgical NEC decreased over time. Incidence and mortality of SIP did not significantly change. CONCLUSION: A regional QI bundle to reduce the overall incidence of NEC also significantly decreased the incidence of surgical NEC and all-cause mortality of infants diagnosed with surgical NEC. KEY POINTS: · QI reduces surgical necrotizing enterocolitis.. · Reduction in NEC rate improves mortality.. · Human milk does not change SIP incidence..

Pediatric Intestinal Transplantation Management and Outcomes.

Intestinal failure is the anatomic or functional loss of intestinal function below the minimum required to absorb nutrients to maintain health and growth. Parenteral nutrition is the main supportive therapy for children with intestinal failure, but if serious complications develop, intestinal transplantation may be needed to sustain life. Referral to a multidisciplinary intestinal rehabilitation team and an extensive evaluation are necessary steps before listing for transplantation. Immunosuppression is part of life-long therapy after transplantation, and children continue to have high medical needs. Serious complications include acute cellular rejection, graft-versus-host disease, infection, and post-transplant lymphoproliferative disease. However, intestinal transplantation has led to improved outcomes in recent years and is a viable life-saving option for many children with intestinal failure.

Body Composition of Very Low-Birth-Weight Infants Fed Fortified Human Milk: A Pilot Study.

BACKGROUND: Although donor milk is increasingly fed to preterm infants, the resultant quality of growth and body composition is unknown. The aim of this pilot study was to describe the body composition of very low-birth-weight infants fed human milk in the neonatal intensive care unit and explore the association between the proportion of donor human milk intake and fat-free and fat mass deposition. METHODS: Body composition of 30 preterm infants fed maternal and donor human milk was measured by air displacement plethysmography. Regression models were developed to associate each parameter of body composition with the proportion of donor milk intake and other explanatory variables. RESULTS: The proportion of donor milk intake was negatively associated with body fat percentage (P = .01). Fat-free mass z-scores ranged from -4.6 to 1.11 (mean z-score of -0.95, 17th percentile). CONCLUSION: Donor human milk intake is negatively associated with body fat percentage in this pilot study of very low-birth-weight preterm infants.

Delay in achieving enteral autonomy and growth outcomes in very low birth weight infants with surgical necrotizing enterocolitis.

OBJECTIVE: To understand the nutritional intake and growth outcomes of very low birth weight infants with surgical necrotizing enterocolitis (NEC). STUDY DESIGN: In a retrospective cohort study, linear mixed models were used to compare growth outcomes from birth to 24 months corrected age for very low birth weight (VLBW) infants with surgical NEC to those with spontaneous intestinal perforation (SIP). Kaplan-Meier curves were developed to demonstrate the duration of parenteral nutrition (PN) use. RESULT: Height differed by surgical NEC and SIP over time (interaction p = 0.03). Surviving infants with surgical NEC had lower head circumference z-scores at 24 months. Of infants surviving surgical NEC, 71% received PN for >60 days after diagnosis. CONCLUSION: The majority of infants with surgical NEC have a delay in achieving enteral autonomy. There was a difference in linear catch-up growth over time between infants with SIP and surgical NEC at 24 months.

Effect of parenteral nutrition duration on patterns of growth and body composition in very low-birth-weight premature infants.

BACKGROUND: Parenteral nutrition (PN) is essential to support premature infants' growth and varies with enteral nutrition (EN) advancement rates. Data on PN duration's impact on premature infants' growth are limited. The aim of this multicenter observational study was to determine the effect of early PN duration on body composition at term corrected gestational age (CGA) in very low-birth-weight (VLBW) premature infants. METHODS: VLBW infants exposed to PN in the first week of life and exposed to significantly different EN regimens were divided into two groups on the basis of early PN duration. Infants with a birth weight (BW) <1000 g and PN duration <28 days and infants with a BW 1000-1500 g and PN duration <14 days were assigned to the "short-PN" group. Infants receiving PN for longer durations were assigned to the "long-PN" group. Body composition was assessed via air displacement plethysmography at term CGA or before discharge. RESULTS: Sixty-two and 53 infants were assigned to the short-PN and long-PN groups, respectively. The two groups were significantly different in BW and GA, so a nested case-control study was conducted after matching 36 infant pairs. Infants in the long-PN group had significantly lower fat-free mass (FFM) z-scores, but both groups had comparable fat mass (FM) z-scores. Long PN was a significant negative predictor of FFM z-score in the multivariate regression analysis. CONCLUSION: In VLBW premature infants, PN duration is negatively associated with FFM z-scores at term CGA without affecting FM z-scores.

Hepatic Steatosis in Infancy: The Beginning of Pediatric Nonalcoholic Fatty Liver Disease?

Nonalcoholic fatty liver disease is clinically silent and the age of its onset is unknown. Fatty liver can occur as early as in utero in the context of an unfavorable maternal metabolic environment. Our objective was to determine the prevalence of hepatic steatosis in a cohort of previously healthy infants less than 3 months of age. Methods: Retrospective study of all abdominal computed tomography (CT) scans performed from 2009 to 2019 for the investigation of trauma. Two independent reviewers applied published criteria to determine the presence of hepatic steatosis. Descriptive statistics were used. The groups with and without steatosis were compared using Wilcoxon-Mann Whitney or Fisher exact test. Results: Of 119 CT scans available in infants younger than 3 months of age, 65 were performed in previously healthy infants for the investigation of trauma. The included population was predominantly male, non-Hispanic, with a median age of 60 days (interquartile range, 34-73 d). Depending on the criteria used, 23% or 26% of infants had evidence of fatty liver. The prevalence of maternal obesity and/or diabetes was 11% (of the 65 pregnancies) but there was no significant difference in maternal risk factors between infants with and without evidence of steatosis. Conclusions: Findings suggest CT evidence of hepatic steatosis in up to a quarter of otherwise healthy infants ≤3 months of age. This may represent early manifestation of pediatric nonalcoholic fatty liver disease. The natural history and pathophysiology of this condition need to be studied to determine optimal detection, prevention and early intervention strategies.

Infant body composition assessment in the neonatal intensive care unit (NICU) using air displacement plethysmography: Strategies for implementation into clinical workflow.

Nutritional management is integral to infant care in the neonatal intensive care unit (NICU). Recent research on body composition that specifically evaluated fat and fat-free mass has improved our understanding of infant growth and nutritional requirements. The need for body composition monitoring in infants is increasingly recognized as changes in fat mass and fat-free mass associated with early growth can impact clinical outcomes. With the availability of air displacement plethysmography (ADP) as a noninvasive method for assessing infant body composition and published normative gestational age- and sex-specific body composition curves, it is justifiable to integrate this innovation into routine clinical care. Here we describe our experiences in implementing body composition measurement using ADP in routine clinical care in different NICU settings.

Nutrition for the Extremely Preterm Infant.

With advancements in the care of preterm infants, the goals in nutritional care have expanded from survival and mimicking fetal growth to optimizing neurodevelopmental outcomes. Inadequate nutritional support may be a risk factor for major complications of prematurity; conversely, higher disease burden is a risk for growth restriction. Early complete parenteral nutrition support, including intravenous lipid emulsion, should be adopted, and the next challenge that should be addressed is parenteral nutrition customized to fit the specific needs and metabolism of the extremely preterm infant. Standardized feeding protocols should be adopted.

Standardized Slow Enteral Feeding Protocol and the Incidence of Necrotizing Enterocolitis in Extremely Low Birth Weight Infants.

BACKGROUND: Compared with early enteral feeds, the delayed introduction and slow advancement of enteral feedings to reduce the incidence of necrotizing enterocolitis (NEC) are not well studied in extremely low birth weight (ELBW) infants. OBJECTIVE: To study the effects of a standardized slow enteral feeding (SSEF) protocol in ELBW infants. METHODS: ELBW infants who followed an SSEF protocol (September 2009 to December 2012) were compared with a similar group of historical controls (January 2003 to July 2009). Short-term outcomes between the 2 groups were compared by propensity score (PS) analysis. RESULTS: One hundred twenty-five infants in the SSEF group were compared with 294 historical controls. Compared with the controls, feeding initiation day, full enteral feeding day, parenteral nutrition (PN) days, and total central line days were longer in the SSEF group. There was no significant difference in overall NEC (5.6% vs 11.2%, respectively; P = .10) or surgical NEC (1.6% vs 4.8%, respectively; P = .17) between the SSEF group and controls. However, in infants with birth weight <750 g, NEC (2.1% vs 16.2%, respectively; P < .01) or combined NEC/death (12.8% vs 29.5%, respectively; P = .03) was significantly less in the SSEF group compared with controls. In infants who survived to discharge, there was no significant difference in the discharge weight or length of stay in PS-adjusted analysis. CONCLUSIONS: An SSEF protocol significantly reduces the incidence of NEC and combined NEC/death in infants with birth weight <750 g. Despite taking longer to achieve full enteral feeding on this protocol, surviving ELBW infants demonstrated comparable weight gain at discharge without prolonging their hospital stay.

Metabolic bone disease: a continued challenge in extremely low birth weight infants.

BACKGROUND: Metabolic bone disease (MBD) is an important prematurity-related morbidity, but remains inadequately investigated in extremely low birth weight (ELBW) infants, the group most at risk. The objective was to describe the incidence and associated risk factors of MBD in ELBW infants. METHODS: Retrospective analysis of all ELBW infants admitted between January 2005 and December 2010 who survived > 8 weeks. MBD was defined as the presence of osteopenia or rickets in radiographs. RESULTS: Of the 230 infants included in the study, 71 (30.9%) developed radiological evidence of MBD (cases) of which 24/71 (33.8%) developed spontaneous fractures. MBD and fractures were noted at mean postnatal ages of 58.2 ± 28 and 100.0 ± 61 days, respectively. Compared with controls, cases were smaller at birth (664.6 ± 146 g vs 798.1 ± 129 g), more premature (25.0 ± 1.8 vs 26.4 ± 1.9 weeks), more frequently associated with mechanical ventilation, chronic lung disease, parenteral nutrition days, cholestasis, furosemide, postnatal steroids, and antibiotics use (all P < .01). Cases had lower average weekly intake of calcium, phosphorous, vitamin D, protein, and calories during the first 8 weeks of life compared with controls. Cases with MBD, compared with controls, had higher mortality (14.1 vs 4.4%) and longer hospital stay (140.2 ± 51 vs 101.0 ± 42 days; P < .01). CONCLUSIONS: MBD remains an important morbidity in ELBW infants despite advances in neonatal nutrition. Further research is needed to optimize the management of chronic lung disease and early nutrition in ELBW infants.

Premature thelarche in infants and toddlers: prevalence, natural history and environmental determinants.

STUDY OBJECTIVE: The aim of this study was to measure the prevalence of premature thelarche in infant and toddler girls and to determine if environmental sources of estrogen were associated with early breast development. DESIGN: Observational with mixed methods: Retrospective chart review, cross-sectional component involving an interview survey, along with longitudinal follow-up of girls with thelarche up to six months. SETTING: A general pediatric clinic within a teaching hospital located in a large Midwestern city. PARTICIPANTS: Girls, between the ages of 12 and 48 months, and their mothers, presenting for well-child care. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Prevalence of premature thelarche; association of premature thelarche with selected environmental exposures. RESULTS: Among the 318 subjects, the overall prevalence of premature thelarche was measured at 4.7% (n = 15). The prevalence by race/ethnicity was 4.2% among White Non-Hispanics, 4.6% among Blacks and 6.5% among White Hispanics. The peak prevalence occurred between 12-17 months of age. All thelarche cases were Tanner stage 2. No statistically significant relationship was found between premature thelarche and environmental exposures. Upon follow-up, 44% of the cases of premature thelarche had persistent breast development. CONCLUSIONS: Our study demonstrated a higher prevalence of premature thelarche than has been previously reported. This study lacked power because of the small number of premature thelarche cases, the ubiquitous presence of environmental exposure as well as the potentially small effect of each environmental factor. Future studies need to employ a very large sample in order to accurately analyze the relationship between environmental toxicants and premature thelarche.