A recent ‘clinical quality forum’ sponsored by The Children’s Care Network (TCCN) and Nutrition4Kids featured several good lectures. The symposium was titled, “It’s Alimentary.” What follows are my notes –the full lectures from these talks will be available in the coming weeks on the Nutrition4Kids website. My notes may include some errors in transcription and errors of omission.
In my view the best lecture from this symposium was given by Kathleen Zelman (WebMD, Director of Nutrition): Diet and Nutrition Trends Impacting Health
- There have been more individuals pursuing vegetarian and vegan diets. Though increasing vegetables/fruits is a good trend, vegan diets are particularly challenging (& potentially dangerous) in children. In those who take milk and eggs, this diet is much more likely to meet nutrient needs. These diets necessitate the assistance of a dietician.
- Unfavorable trends: increased consumption of highly processed foods and restrictive food fads. Some processed foods (eg. canned beans) can be a healthy addition to diet.
- ‘Organic diets are not more nutritious. They are great if you can afford it. Key is eating more vegetables and fruits.’
- GMOs are safe.
- MyPlate.gov is a good resource
- Encourage families to eat together and to shop for a ‘rainbow of colors’
A subsequent lecture on “Nutrition for the Premature Infant” by Heidi Karpen (Emory University, Professor of Pediatrics) provided a good overview of the ongoing efforts to improve nutritional outcomes for premature infants.
- Good nutrition is crucial for better neurodevelopmental outcomes and stronger bones.
- Despite efforts like instituting TPN on first day of life, most neonates are losing ground during their hospitalization.
- Breastmilk is best at reducing sepsis, necrotizing enterocoliitis, and improving IQ. However, it is not perfect –less protein, less calcium, and less phosphorus than formulas; thus, breastmilk needs to be augmented and/or supplemented.
- Informal breastmilk donation can be dangerous. Donor breastmilk needs to be carefully screened.
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Since a trial which randomizes premature infants into groups that are well-nourished and poorly-nourished and then following them prospectively is never going to happen, it is difficult to know with certainty the effects of optimal nutrition are with respect to long-term neurodevelopmental outcomes.
An article I enjoyed reading on this subject (MB Belfort et al. J Pediatr 2016; 168: 30-5) pushes back on the correlation between good weight gain, as a surrogate marker for nutritional status, and neurodevelopmental outcomes.
In this study, 1070 infants between 23-27 weeks gestational age were followed with weights on days 7-28 along with weights at 12 and 24 months. This data was compared with several indices on neurodevelopmental outcome. Here is the key finding: “Weight gain in the lowest quartile from 7-28 days was not associated with higher risk of adverse outcomes.”
In commentary on their findings, the authors point out that “we found no evidence to suggest that faster weight gain from 7 to 28 days of life reduced the risk of adverse outcomes…almost all of the associations between low weight gain..were attenuated or eliminated when we restricted our analysis to those children able to walk independently.”
“Overall, it appears that low weight in children with severe neurodevelopmental impairments may be caused by factors closely related to the impairments themselves…reverse causation may be at play.” Thus, underlying brain damage may limit body weight gain, rather than poor nutrition limiting brain development.”
My take: I may be apt to ‘confirmational bias’ as this study reinforces my view that improved nutrition may not change outcomes appreciably. To be clear, I still believe that efforts to optimize the nutrition of premature infants are a good idea but we need to be skeptical about the magnitude of benefit that we will derive.
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A Few Years Ago in Yosemite
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.