A recent terrific lecture at Northside Hospital’s neonatology conference by Reese Clark highlighted what we know about neonatal nutrition and what we should be striving to achieve. This blog entry has abbreviated/summarized this presentation. Though not intentional, some important material is likely to have been omitted; in addition, transcription errors are possible as well.
Dr. Clark was willing to share slides from his talk and a related talk on necrotizing enterocolitis:
Here are a couple of key points from his talk regarding postnatal growth and feedings:
- Every baby needs good nutrition. While this is an obvious point, a lot of effort is focused on aspects of care needed in only a small number of neonates.
- New target for weight gain in premature infants should be 20 gm/kg/day. This growth is associated with better outcomes (Pediatrics 2006; 117: 1253 Ehrenkranz RA). In this study, which controlled for a large number of variables, those in the top quartile of growth had much lower rates of cerebral palsy and neurologic impairments. These improvements were also significant when comparing those in the top quartile to those in the 2nd and 3rd quartiles who were not sicker than those in the top quartile.
- Most premature neonates are not achieving adequate growth with z-scores for weight and height lower at discharge from the NICU than their z-scores at birth. That is, despite advances in enteral and parenteral nutrition, premature neonates are falling behind while in the NICU. (Clark RH, et al. Pediatrics 2003; 111: 986)
- Recognizing the supremacy of human milk has been the most important advance and has lead to much lower rates of necrotizing enterocolitis. There is now a great case for exclusive human milk (J Pediatr 2013; 163: 1592-95; BMC Res Notes 2013; 6: 459)
- With parenteral nutrition, higher amounts of amino acid have been associated with less issues with hyperglycemia. (Pediatrics 2007; 120: 12: 86-96; Pediatrics 2013; 163: 1278-82)
- Insulin for hyperglycemia has been associated with poorer outcomes.
- Does carnitine help with lipid metabolism? No one really knows –no randomized trials.
- Continuous NG feeds are not associated with fewer signs/symptoms (e.g.. apnea, bradycardia, arching) than NG bolus feeds.
- Acid suppression in neonates is not effective and potentially harmful
- We need to use the best growth curves for premature infants: Fenton and Olsen growth charts
Since there are not going to be any trials randomizing neonates into groups assigned to poor growth, we will not know with certainty the impact of good nutrition on long-term outcomes. Issues with reverse causation and selection bias make it difficult to know whether those with poor growth had other factors besides their nutritional plan which contributed to their outcomes.
Bottomline: We need to continue to optimize nutrition in premature infants; this includes using human milk and preventing necrotizing enterocolitis (which includes avoid acid blockers). Our goal should be to have infants leave the NICU better nourished than when they arrived.
Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.