两种脂肪乳剂不同肠外营养时间对早产儿临床结局影响的比较:一项随机对照多中心研究北大核心CSCD

目的比较两种脂肪乳剂不同肠外营养时间对早产儿临床结局的影响。方法将符合纳入标准的早产儿随机分为两组:中/长链脂肪乳(medium/long-chain triglyceride fat emulsion,简称MCT/LCT)组和多种油脂肪乳[含大豆油、中链甘油三酯、橄榄油、鱼油(soybean oil,medium-chain triglycerides,olive oil,and fish oil),简称SMOF]组。根据肠外营养持续时间(15~21 d、22~28 d、≥29 d)分层分析,比较两组早产儿的临床特征、营养状况、生化指标和临床结局。结果与MCT/LCT组相比,SMOF组肠外营养持续时间分别为15~21 d、22~28 d、≥29 d的早产儿住院期间甘油三酯的峰值水平均较低(P<0.05)。logistic回归趋势性分析显示,随着肠外营养时间延长,MCT/LCT组早产儿肠外营养相关性胆汁淤积症(parenteral nutrition-associated cholestasis,PNAC)及支气管肺发育不良(bronchopulmonary dysplasia,BPD)的发生风险均明显增高(P<0.05),脑损伤的发生风险无明显变化(P>0.05);SMOF组早产儿随着肠外营养时间延长,PNAC及BPD的发生风险均无明显变化(P>0.05),而脑损伤的发生风险明显降低(P=0.006)。结论与MCT/LCT相比,SMOF具有较好的脂质耐受性;随着肠外营养持续时间延长,SMOF不增加PNAC、BPD的发生风险,且对脑损伤具有保护作用,表明在需要长期肠外营养的早产儿中使用SMOF优于MCT/LCT。     

Very early feeding in stable small for gestational age preterm infants: a randomized clinical trial

ObjectiveTo examine the effect of initiating very early feeding on time-to-reach full feeding in stable, small for gestational age (SGA) preterm infants.MethodPreterm infants with gestational age below 37 weeks and birth weight below the 10^th percentile were randomly allocated to a very early (within 24 hours of birth) feeding regimen or delayed (after 24 hours of birth) feeding. All infants had in utero evidence of absent or reverse diastolic flow. Infants unable to start early feeding were excluded. Time-to-reach full feeding, feeding progression, and related morbidity were compared. Electrogastrography (EGG) was used to measure pre- and postprandial gastric motility on the second and seventh day after feeding initiation.ResultsSixty infants were included in the study, 30 in each group. Infants included in the very early feeding regimen achieved full enteral feeding sooner than controls (98 ± 80-157 vs. 172 ± 123-261 hours of age, respectively; p = 0.004) and were discharged home earlier (p = 0.04). No necrotizing enterocolitis (NEC) was documented in both study groups. Gastric motility was improved at day seven after feeding initiation in both study groups, with no difference between groups.ConclusionsStable SGA preterm infants on a very early feeding regimen achieved full enteral feeding and were discharged home significantly earlier than those on a delayed regimen, with no excess morbidity.     

Effects of pre-feeding oral stimulation on oral feeding in preterm infants: A randomized clinical trial

Objective

To evaluate the effect of early oral stimulation before the introduction of oral feeding, over the duration of concomitant tube feeding (“transition period”), the length of hospital stay and the breastfeeding rates upon discharge in preterm infants.

Study design

Preterm infants born between 26 and 33 weeks gestational age (n = 86), were randomized into an intervention and control group. Infants in the intervention group received an oral stimulation program consisting in stimulation of the oral structures for 15 min at least for 10 days, before introduction of oral feeding. Oral feeding was introduced at 34 weeks GA in both groups.

Results

Breastfeeding rates upon discharge were significantly higher in the intervention than in the control group (70% versus 45.6%, p = 0.02). There was no statistical difference between the two groups in terms of the length of the transition period or the length of the hospital stay.The need for prolonged CPAP support (HR = 0.937, p = 0.030) and small size for gestational age at birth (HR = 0.338, p = 0.016) were shown to be risk factors for a prolonged transition period.

Conclusion

A pre-feeding oral stimulation program improves breastfeeding rates in preterm infants. The study results suggest that oral stimulation, as used in our specific population, does not shorten the transition period to full oral feeding neither the length of hospital stay.     

Effect of holding on co-regulation in preterm infants: A randomized controlled trial

Objective

To determine whether kangaroo holding of healthy preterm infants over the first eight weeks of an infant's life facilitates co-regulation of salivary cortisol between mother and infant.

Study Design

Randomized control trial. Infants were assigned to receive 1 h of daily kangaroo (skin-to-skin contact on the chest of mother) or blanket holding (dressed and held in mother's arms). A registered nurse visited mothers weekly for eight weeks to encourage holding and provide information about infant development. A control group had no holding restrictions and received weekly brief social visits.

Subjects

The study included 79 preterm infants, born between 32 and 35 weeks gestational age and were a mean of 15 days (± 5.7) at enrollment.

Outcome Measures

Co-regulation was conceptualized as progressive reduction in the absolute difference between mother and infant cortisol levels across 60 min of holding at each holding session. Mother and infant cortisol levels were measured before holding and at 30 and 60 min after holding began during three holding sessions (baseline and at two and eight weeks after study initiation). Primary analyses were conducted using hierarchical linear models.

Results

There was much variability in cortisol levels. Levels of mother and infant cortisol decreased during holding. No significant co-regulation occurred in any group at any holding session or over time.

Conclusions

Decreasing level of cortisol in both mothers and infants suggests that holding promoted the expected decline in stress hormone levels. However, supported holding methods did not differentially affect co-regulation compared to controls. Holding is pleasurable and stress may need to be present in order for mothers and infants to demonstrate co-regulation in cortisol levels.     

Enteral erythropoietin increases plasma erythropoietin level in preterm infants: a randomized controlled trial

OBJECTIVE: To evaluate the effects of enteral administration of recombinant human erythropoietin (rhEPO) on serum level of erythropoietin and erythropoiesis in preterm infants. STUDY DESIGN: Randomized controlled trial. SETTING: Level III NICU. SUBJECTS: 16 preterm infants less than 34 wk with birth weight less than 1800 g. INTERVENTION: Enteral rhEPO 400 U/kg, three times/week, plus FeSO4,3-6 mg/Kg/day ( Study group, n = 7) or FeSO4 only (Control group, n = 9). OUTCOME MEASURES: Hemoglobin, serum erythropoietin (EPO), reticulocyte count, and serum ferritin levels, measured at baseline, after 10 days and at discharge. RESULTS: Mean birth weight and gestational age for the Study and the Control groups were 1328.5 +/- 267.4 vs. 1392.8 +/- 196.7 g and 30.7 +/- 2.5 vs. 30.2 +/- 0.9 weeks, respectively. At discharge, there was no difference in hemoglobin or hematocrit but the reticulocyte counts were significantly higher in the Study group (1.4 +/- 0.7 vs. 0.7 +/- 0.4, P = 0.03). Serum erythropoietin level was significantly higher in the Study group (18 +/- 11 vs. 8.6 +/- 3.9 mU/mL, P = 0.006). Conversely, serum ferritin level was lower in the study group but did not achieve statistical significance. CONCLUSIONS: Enteral administration of rhEPO in preterm infants resulted in increase in serum erythropoietin and reticulocyte counts at the time of discharge without significantly affecting hemoglobin or hematocrit.     

Cisapride may improve feeding tolerance of preterm infants: a randomized placebo-controlled trial

To evaluate the efficacy of cisapride in improving tolerance of enteral feeding, 59 premature infants were randomized into a blinded placebo-controlled study. Treatment was initiated with the introduction of enteral feeding and continued until 150 ml/kg/day of milk were tolerated. Only in extremely low birth weight (ELBW) infants, was the time to tolerate full enteral feeding shorter in the treatment group, whereas ECG recordings showed a significantly prolonged QTc interval during treatment. Two children developed cardiac rhythm disturbances. In conclusion premature infants may not benefit from routine use of the drug to improve enteral feeding, and seem to be more vulnerable to its side effects.     

Parenteral nutrition for preterm infants: Issues and strategy

Due to transient gut immaturity, most very preterm infants receive parenteral nutrition (PN) in the first few weeks of life. Yet providing enough protein and energy to sustain optimal growth in such infants remains a challenge. Extrauterine growth restriction is frequently observed in very preterm infants at the time of discharge from hospital, and has been found to be associated with later impaired neurodevelopment. A few recent randomized trials suggest that intensified PN can improve early growth; whether or not such early PN improves long-term neurological outcome is still unclear. Several other questions regarding what is optimal PN for very preterm infants remain unanswered. Amino acid mixtures designed for infants contain large amounts of branched-chain amino acids and taurine, but there is no consensus on the need for some nonessential amino acids such as glutamine, arginine, and cysteine. Whether excess growth in the first few weeks of life, at a time when very preterm infants receive PN, has an imprinting effect, increasing the risk of metabolic or vascular disease at adulthood continues to be debated. Even though uncertainty remains regarding the long-term effect of early PN, it appears reasonable to propose intensified initial PN. The aim of the current position paper is to review the evidence supporting such a strategy with regards to the early phase of nutrition, which is mainly covered by parenteral nutrition. More randomized trials are, however, needed to further support this type of approach and to demonstrate that this strategy improves short- and long-term outcome.     

Stepping up versus standard doses of erythropoietin in preterm infants: a randomized controlled trial

In this study, it is hypothesized that a planned increase in the dose of recombinant human erythropoietin (rh-EPO) can prevent transfusion in very low birth weight infants. Two different regimens of rh-EPO were administrated, one consisting in increasing dosage up to 5000 U/kg/wk, according to the individual reticulocytes response, and the second in a standard therapy of 1250 U/kg/wk. Fifty-one infants participated. Despite a significant higher reticulocytosis, the study was prematurely terminated due to the results of an interim analysis showing that transfusion was not avoided by increasing the rh-EPO. No significant differences were found between the two regimens concerning transfusion rate, volume transfused, gain in weight, and adverse effects. Progressive titration of rh-EPO to improve the biological response does not leave premature infants free of transfusion.     

Ursodeoxycholic acid prevention on cholestasis associated with total parenteral nutrition in preterm infants:a randomized trial

Background Preterm infants with long-term parenteral nutrition(PN)therapy are at risk for cholestasis associated with total parenteral nutrition(PNAC).This study examined the safety and efficacy of ursodeoxycholic acid(UDCA)in preventing PNAC in preterm infants.Our research aimed to investigate the prophylactic effect of preventive oral UDCA on PNAC in preterm infants.Methods We compared oral administration of UDCA prophylaxis with no prophylaxis in a randomized,open-label,proof-of-concept trial in preterm neonates with PN therapy.The low-birth-weight preterm infants(<1800 g)who were registered to the neonatal intensive care unit(NICU)within 24 hours after birth were randomized.The main endpoint was the weekly values of direct bilirubin(DB)of neonates during the NICU stay.Results Eventually,a total of 102 preterm neonates from January 2021 to July 2021 were enrolled in this prospective study(42 in the UDCA group and 60 in the control group).Notably,the peak serum level of DB[13.0(12-16)vs.15.2(12.5-19.6)μmol/L,P<0.05]was significantly lower in the UDCA group than that in the control group without prevention.The peak serum level of total bilirubin(101.1±34 vs.116.5±28.7μmol/L,P<0.05)was also significantly lower in the UDCA group than in the control group.Furthermore,the proportion of patients who suffered from neonatal cholestasis(0.0%vs.11.7%,P<0.05)in the UDCA group was significantly lower.Conclusion UDCA prophylaxis is beneficial in preventing PNAC in NICU infants receiving prolonged PN.     

Skin exposure during conventional phototherapy in preterm infants: A randomized controlled trial

OBJECTIVE: To assess the effect of reduced skin exposure in preterm infants receiving overhead phototherapy treatment on total serum bilirubin (TSB). METHODS: Randomized controlled trial. Preterm infants (>1500 g birthweight and < or = 36 weeks gestation) were randomized to being nursed either partially clothed with only disposable nappies and in posturally supported positions (n = 30) or naked without postural support (n = 29). Primary outcome was mean TSB percentage change at 24 h of completed conventional overhead phototherapy treatment (irradiance of 6 microW cm(-2)/nm at a wavelength of 425-475 nm). The incidence of rebound jaundice, number of infants continuing to receive phototherapy treatment at 24 h periods, parental stress, mother-infant interaction and mean TSB percentage change at 24 h of completed conventional overhead phototherapy treatment were examined. RESULTS: Mean TSB percentage change at 24 h of completed treatment for the partially clothed group was 15.4% (+/-18) and for the naked group 19% (+/-15) (mean difference 3.6% 95% CI -5.1, 12.3). No other outcomes were significantly affected by reduced skin exposure to overhead phototherapy treatment. CONCLUSION: Our results show no statistically significant difference in TSB level change using either nursing practice.