Nutrient needs and feeding of premature infants. Nutrition Committee, Canadian Paediatric Society.

OBJECTIVE: To recommend appropriate intake of nutrients, food sources and feeding practices for premature infants. OPTIONS: Unfortified milk from the premature infant's own mother, fortified milk from the premature infant's own mother, formula designed for preterm infants and parenteral nutrition. OUTCOMES: From birth to 7 days, the minimum achievable goal is the provision of sufficient nutrients to prevent deficiencies and catabolism of nutrient substrate in premature infants; from 7 days to discharge from the neonatal intensive care unit, growth and nutrient retention at a rate similar to that which would have been achieved had the infant remained in utero; and for 1 year following discharge, nutrient intake to achieve catch-up growth. EVIDENCE: Few randomized clinical trials of feeding infants specific nutrients or of feeding choices have been conducted. On the basis of a MEDLINE search of the literature, committee members prepared reviews of the available information on each nutrient and feeding choice. The reviews were critically appraised by the committee. Recommendations were based on the consensus of the committee. VALUES: Whenever possible, the evidence was weighed in favour of randomized controlled trials. If such trials were unavailable, cohort studies were considered. If trials of either kind were unavailable, published data were reviewed and recommendations were based on consensus opinion. BENEFITS, HARMS AND COSTS: The advantages of feeding premature infants unfortified milk from their own mothers are psychologic benefits for the mother as well as anti-infective benefits and possibly improved intellectual development for the infant. However, unfortified milk from the infant's own mother is inadequate as a sole source of nutrients. The use of fortified milk from the mother results in faster growth as well as having the other benefits of mother's milk. When formulas designed for premature infants are given in adequate volumes, they provide an intake of nutrients that allows the infant to duplicate intrauterine growth without undue metabolic stress. RECOMMENDATIONS: The preferred food for premature infants is fortified milk from the infant's own mother or alternatively, formula designed for premature infants. This recommendation applies to infants with birth weights of a minimum of 500 g to a maximum of 1800 to 2000 g, or with a gestational age at birth of a minimum of 24 weeks to a maximum of 34 to 38 weeks (until the infant is able to nurse effectively). VALIDATION: These guidelines are in line with, but not identical to, recent guidelines by the Committee on Nutrition of the American Academy of Pediatrics and the Committee on Nutrition of the Preterm Infant of the European Society of Paediatric Gastroenterology and Nutrition. SPONSOR: The preparation of these guidelines was sponsored and funded by the Canadian Paediatric Society.     

The Nutrition Canada Survey: a review. Statement by the Nutrition Committee of the Canadian Paediatric Society.

The data obtained through the Nutrition Canada national nutrition survey must be interpreted cautiously because of limitations in both the design of the survey and our present knowledge of the implications of the findings. The data suggest that, at present, nutritional status is suboptimal among members of the general population. However, because there is no evidence of clinically apparent malnutrition it is difficult to judge the immediate health significance of this finding. Among the Inuit, however, the data suggest that intake of vitamin C may be sufficiently low to approach the level causing clinical problems. Government should make funds available to permit analysis of the data to be completed and investigative studies to be undertaken to assess the health significance of the findings.     

Neonatal circumcision revisited. Fetus and Newborn Committee, Canadian Paediatric Society.

OBJECTIVE: To assist physicians in providing guidance to parents regarding neonatal circumcision. OPTIONS: Whether to recommend the routine circumcision of newborn male infants. OUTCOMES: Costs and complications of neonatal circumcision, the incidence of urinary tract infections, sexually transmitted diseases and cancer of the penis in circumcised and uncircumcised males, and of cervical cancer in their partners, and the costs of treating these diseases. EVIDENCE: The literature on circumcision was reviewed by the Fetus and Newborn Committee of the Canadian Paediatric Society. During extensive discussion at meetings of the committee over a 24-month period, the strength of the evidence was carefully weighed and the perspective of the committee developed. VALUES: The literature was assessed to determine whether neonatal circumcision improves the health of boys and men and is a cost-effective approach to preventing penile problems and associated urinary tract conditions. Religious and personal values were not included in the assessment. BENEFITS, HARMS AND COSTS: The effect of neonatal circumcision on the incidence of urinary tract infection, sexually transmitted diseases, cancer of the penis, cervical cancer and penile problems; the complications of circumcision; and estimates of the costs of neonatal circumcision and of the treatment of later penile conditions, urinary tract infections and complications of circumcision. RECOMMENDATION: Circumcision of newborns should not be routinely performed. VALIDATION: This recommendation is in keeping with previous statements on neonatal circumcision by the Canadian Paediatric Society and the American Academy of Pediatrics. The statement was reviewed by the Infectious Disease Committee of the Canadian Paediatric Society. The Board of Directors of the Canadian Paediatric Society has reviewed its content and approved it for publication. SPONSOR: This is an official statement of the Canadian Paediatric Society. No external financial support has been received by the Canadian Paediatric Society, or its members, for any portion of the statement's preparation.     

Short-course therapy for tuberculosis in infants and children. Infectious Diseases and Immunization Committee, Canadian Paediatric Society.

OBJECTIVE: To improve efficacy of and compliance with therapy for tuberculosis in children. OPTIONS: Short-course (6-month) multi-drug therapy, either non-supervised or directly supervised, versus long-course (more than 6-month) multi-drug therapy. OUTCOMES: Success (more than 90% of cases cured without relapse or serious side effects), development of drug resistance and compliance with treatment. EVIDENCE: Review of published reports of efficacy trials of tuberculosis therapy in children, side effects and compliance studies; consensus of expert opinion. VALUES: Values were assigned to the evidence by the Infectious Disease and Immunization Committee of the Canadian Paediatric Society through review of the data and consensus. BENEFITS, HARMS AND COSTS: Improved efficacy and compliance with short-course protocols should lower the rate of treatment failure among children in Canada and the cost of tuberculosis care. RECOMMENDATIONS: A short-course (6-month) protocol of four drugs for the first 2 months and two drugs for the subsequent 4 months is recommended to treat pulmonary tuberculosis or extrapulmonary disease causing lymphadenopathy. Tuberculous meningitis, disease involving bones and joints and tuberculosis with HIV infection require longer courses of treatment. Asymptomatic tuberculosis should be treated with daily doses of isoniazid for 9 months. Intermittent directly observed therapy is recommended if compliance cannot be ensured. Routine liver function testing is not recommended for prepubescent children taking isoniazid, but monthly assessment for clinical symptoms and periodic liver function evaluation is advised in adolescent women, especially post partum. VALIDATION: This report was reviewed by the directors of the Canadian Paediatric Society, the Hepatitis and Special Pathogens Division of the Laboratory Centre for Disease Control and the Canadian Thoracic Society. The recommendations are similar to those of the American Academy of Pediatrics. SPONSOR: The recommendations were developed and endorsed by the Infectious Disease and Immunization Committee of the Canadian Paediatric Society.