Optimising nutrition of preterm and term infants in the neonatal intensive care unit

Optimum nutrition leads to improved long-term neurodevelopmental outcomes in both preterm and term infants admitted to the neonatal intensive care (NICU). This review delineates the phases of nutritional management from full parenteral nutrition, transitioning to enteral nutrition and on to full enteral feeds. It describes the essential components of best nutritional care in the neonatal periods and provides practical tips in the management of nutrition in these infants. The authors make recommendations for care based on national and international guidelines and personal expertise of working in a tertiary NICU.     

关注疾病状态下儿童的营养支持

患儿的营养状况将影响其疾病康复和预后。在我国,对儿科营养重要性的认识和规范化应用,远远落后于发达国家。为进一步提高我国临床各科对此问题的认识,本刊特设此专题进行讨论,十分必要。下面就国内外相关情况     

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??Sepsis is one of important reasons for the death of children in intensive care unit. Although anti-infection and active symptomatic treatment are the key to treatment??whether nutrition support is rational and effective or not can also affect clinical prognosis. Sepsis children are in stress status??so nutrition support needs to meet the demand for energy??protein and other nutrients without increasing the burden of organs. Although intestinal function is damaged because of systemic infection??enteral nutrition??EN?? is still the first choice by actively creating conditions. If the EN is not enough??supplemental parenteral nutrition??PN?? should be given. In the process of nutrition support??immune nutrients can be added to regulate immune function and attenuate inflammation.     

Reduction in postnatal cumulative nutritional deficit and improvement of growth in extremely preterm infants

Aim: To evaluate the influence of gestational age (GA) on cumulative nutritional deficit and postnatal growth in extremely preterm (EPT) infants after optimizing nutritional protocol as recently recommended. Methods: A prospective, nonrandomized, observational study in extremely preterm (EPT, <28 weeks) and very preterm (VPT, 28–30 weeks) infants. Results: Eighty‐four infants were included (BW: 978 ± 156 g, GA: 27.8 ± 1.3 weeks). Cumulative nutritional deficit increased during first week of life to ?290 ± 84 and ?285 ± 117 kcal/kg and ?4.2 ± 3.1 and ?4.8 ± 3.9 g/kg of protein in EPT and VPT groups, respectively. After 6 weeks, only cumulative energy deficit in EPT group remained significant (p < 0.05) even when 96% of theoretical energy intakes were provided. Weight z score decreased during first 3 days in average with initial weight loss, and then, the z score increased during the first 6 weeks of life in the majority (75%) of infants. Cumulative protein deficit during the first week of life was the major determinant of the postnatal growth during the first 6 weeks of life. Conclusion: Cumulative nutritional deficit may be drastically reduced in both EPT and VPT infants after optimizing nutritional policy during the first weeks of life, and the postnatal growth restriction could even be prevented.     

Integrating nutrition into health systems: What the evidence advocates

There is considerable evidence of positive health and nutrition outcomes resulting from integrating nutrition‐specific interventions into health systems; however, current knowledge on establishing and sustaining effective integration of nutrition into health systems is limited. The objective of this review is to map the existing types of integration platforms and review the evidence on integrated health and nutrition programmes' impacts on specific nutrition outcomes. A literature search was conducted, and integrated nutrition programmes were examined through the lens of the six World Health Organization (WHO) building blocks, including the demand side. Forty‐five studies were included in this review, outlining the integration of nutrition‐specific interventions with various programmes, including integrated community case management and Integrated Management of Childhood Illness, Child Health Days, immunization, early child development, and cash transfers. Limited quantitative data were suggestive of some positive impact on nutrition and non‐nutrition outcomes with no adverse effects on primary programme delivery. Through the lens of the six WHO building blocks, service delivery and health workforce were found to be well‐integrated, but governance, information systems, finance and supplies and technology were less well‐integrated. Integrating nutrition‐specific interventions into health systems may ensure efficient service delivery while having an impact on nutrition outcomes. There is no single successful model of integration; it varies according to the context and demands of the particular setting in which integration occurs. There is a need for more well‐planned programmes considering all the health systems building blocks to ensure compliance and sustainability.     

Higher protein and energy intake is associated with increased weight gain in pre‐term infants

Aim: To characterise and compare the nutritional management and growth in infants <33 weeks' gestation in two tertiary centres. Methods: An audit of daily intake and growth from birth to discharge home was undertaken in two neonatal units: The KK Women's and Children's Hospital Singapore and the Adelaide Women's and Children's Hospital, South Australia. Mixed models were used to model intake and daily weight (g/day) accounting for repeated day per subject. Results: The clinical characteristics of the two cohorts were similar. The Adelaide cohort had a higher initial energy intake in the first 5 days compared with the Singapore cohort, and a significantly greater weekly increase of 21.0 kcal/week (95% CI 7.7–34.3; P = 0.002). The Adelaide cohort also had a higher initial protein intake and a significantly greater weekly increase of 0.88 g/week (95% CI 0.5, 1.3), P < 0.001) compared with the Singapore cohort. The weight gain of the Adelaide cohort was 9 g/day more than the Singapore cohort (95% CI 7.3, 10.7; P < 0.001). Post‐natal growth failure was evident in 32% (n = 64) of the Adelaide cohort and 64% (n = 94) of the Singapore cohort. Conclusions: The two centres showed distinct differences in nutritional management. A higher energy and protein intake was associated with improved growth yet growth in both cohorts was still below current recommendations.     

Accuracy of declared nutrient content on labels of commercial complementary food products in Cambodia,Indonesia and Senegal

Commercially produced complementary foods (CPCF) have the potential to fill nutritional gaps in the diets of older infants and young children. This study evaluated the accuracy of nutrient declarations on labels of 43 commonly available CPCF in three peri-urban/urban locations: Khsach Kandal district, Cambodia (n = 11); Bandung, Indonesia (n = 11) and Guédiawaye and Dakar departments, Senegal (n = 21). Label values (LV) from product nutrient declarations were compared to analytical values (AV) derived from laboratory nutrient analysis for macronutrients (carbohydrate, protein and total fat), nutrients of public health concern (saturated fat, total sugar and sodium), and micronutrients of interest (calcium, iron and zinc). European Union guidance for nutrition label accuracy was used to set tolerance ranges for each nutrient LV relative to AV. LV were missing for one or more nutrients in 88.4% (n = 38) of the CPCF products and no CPCF met EU tolerance thresholds for all nine nutrients assessed. Over half of products with LV for key micronutrients (55.6%, n = 10/18) and macronutrients (54.8%, n = 23/42) met tolerances for LV accuracy. Eighty-five percent (n = 11/13) of products with LV for nutrients of public health concern were determined to be accurate. Nutrient content claims for iron appeared on 19 (44.2%) of the 43 products. Of the products which made an iron content claim, 26.3% had inaccurate LV with the majority of these containing less iron than declared. Regulatory action is needed to ensure that CPCF labelling communicates complete and accurate nutrient content information that enables caregivers to make informed decisions for feeding older infants and young children.     

中国新生儿营养支持临床应用指南

该指南目的是建立能够反映当前最佳临床实践,循证的营养支持指南,为临床实践和进一步的临床研究方向提供参考。该指南参考了大量已发表的相关文献,在此基础上,由来自各相关学科的多位专家起草、审阅并反复修改而成。目标人群为早产儿、低体重出生儿等危重新生儿。指南分为肠内营养、肠外营养、肠内肠外营养联合应用三部分。当经口喂养无法满足患儿需要量时,应给予肠内或肠外营养支持。如果患儿存在胃肠道功能障碍,肠外营养是唯一选择。指南最后给出了肠内肠外营养联合应用的计算公式。     

Changing trends in feeding policies for ventilated preterm infants

In 1987 and 1994 all UK regional neonatal intensive care units were questioned about their feeding policies for the ventilated preterm infant. Between 1987 and 1994 there was an increase in the use of milk feeds (59 versus 71%), fortified breast milk (5 versus 72%) and low birthweight formula (41 versus 69%) whilst use of donor breast milk declined (56 versus 22%). Units that gave enteral feeds used significantly less parenteral nutrition ( p < 0.05). Overall there was a tendency towards greater uniformity in feeding policies.     

短肠综合征的营养策略

短肠综合征是儿童肠衰竭的主要原因,由于手术切除、先天性缺陷或与疾病相关的吸收丧失引起,在常规正常饮食下无法维持蛋白质-能量、体液、电解质以及微量营养素的平衡,需要专门的营养治疗,治疗的目标是促进肠道适应以达到肠道自主,同时保持健康的生长和发育。营养治疗策略是异质的和复杂的,须量身定制。对肠外、肠内和口服营养的类型和持续时间尚无循证建议。提倡阶段化营养管理,肠外营养对于短肠综合征的婴儿和儿童的生存至关重要,谨慎的营养策略对于减少肠外营养持续时间以及降低肠外营养相关并发症发生的风险至关重要,鉴于肠道适应的需要,早期开始最低限度的喂养、根据肠道耐受性逐渐增加肠内营养的量、经口腔喂养以及多样化平衡饮食是必要的。母乳和混合饮食是不错的选择。     

重症患儿营养支持的风险和对策

营养支持,包括肠外营养和肠内营养,已成为危重患儿治疗的重要组成部分,营养支持的风险也越来越受到关注.营养支持的并发症包括与营养支持通路相关的机械性损伤、导管相关性血流感染、肠内营养不耐受和代谢性并发症.这些并发症大部分可以预防,评估和控制风险因素是最有效的预防方法,预防和治疗并发症是保证成功进行营养支持、改善患儿预后的关键.     

Use of food labels,awareness of nutritional programmes and participation in the special supplemental program for Women,Infants and Children (WIC): results from the National Health and Nutrition Examination Survey (2005–2006)

Use of nutritional labels in choosing food is associated with healthier eating habits including lower fat intake. Current public health efforts are focusing on the revamping of nutritional labels to make them easier to read and use for the consumer. The study aims to assess the frequency of use of nutritional labels and awareness of the United States Department of Agriculture (USDA) nutritional programmes by low‐income women including those participating in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) as surveyed in the National Health and Nutrition Examination Survey 2005–2006. Many low‐income women do not regularly use the nutrition facts panel information on the food label and less than half had heard of the USDA Dietary Guidelines for Americans (38.9%). In multivariate logistic regression, we found that WIC participation was associated with reduced use of the nutrition facts panel in choosing food products [odds ratio (OR) 0.45, 95% confidence interval (CI) 0.22–0.91], the health claims information (OR 0.54, 95% CI 0.32–0.28) and the information on carbohydrates when deciding to buy a product (OR 0.44, 95% CI 0.20–0.97) in comparison with WIC eligible non‐participants. Any intervention to improve use of nutritional labels and knowledge of the USDA's nutritional programmes needs to target low‐income women, including WIC participants. Future studies should evaluate possible reasons for the low use of nutrition labels among WIC participants in comparison with eligible non‐participants.     

Cash and voucher assistance and children's nutrition status in Somalia

To address ongoing food insecurity and acute malnutrition in Somalia, a broad range of assistance modalities are used, including in‐kind food, food vouchers, and cash transfers. Evidence of the impact of cash and voucher assistance (CVA) on prevention of acute malnutrition is limited in humanitarian and development settings. This study examined the impact of CVA on prevention of child acute malnutrition in 2017/2018 in the context of the Somalia food crisis. Changes in diet and acute malnutrition were measured over a 4‐month period among children age 6–59 months from households receiving household transfers of approximately US$450 delivered either as food vouchers or a mix of in‐kind food, vouchers, and cash. Baseline to endline change in children's dietary diversity, meal frequency, minimum acceptable diet (MAD), mid‐upper arm circumference (MUAC), and acute malnutrition (MUAC < 12.5 cm) were compared using difference‐in‐difference analysis with inverse probability weighting. There were no statistically significant changes in dietary diversity, meal frequency, or the proportion of children with MAD for either intervention group. Adjusted change in mean MUAC showed increases of 0.5 cm (confidence interval [CI; 0.0, 0.7 cm]) in the food voucher group and 0.1 cm (CI [?0.1, 0.4]) in the mixed transfer group. In adjusted analysis, prevalence of acute malnutrition among children under 5 years increased by 0.7% (CI [?13.4, 14.4%]) among food voucher recipients and decreased by 4.8% (CI [?9.9, 8.1%]) in mixed transfer recipients. The change over time in both mean MUAC and acute malnutrition prevalence was similar for both interventions, suggesting that cash and vouchers had similar effects on child nutrition status.     

Parenteral nutrition in the neonate

Parenteral nutrition has become an integral part of the support of the neonate who is either unable to receive or tolerate enteral feeding. The nutrient requirements for basal metabolism and growth can be provided by the infusion of a mixture of amino acids, glucose, lipids and other additives. By these means, growth can be promoted in infants who would otherwise be susceptible to problems associated with malnutrition. Careful assessment for the need for parenteral nutrition and monitoring during its administration may reduce the incidence of various complications associated with its use. Requirements of various nutrients, modes of delivery and suggested monitoring schedules are discussed.     

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??Nutrition support is an essential management of critically ill patients??and enteral nutrition conforms to the physiological state of the body??which can maintain the integrity of intestinal mucosal structure and function??thus ensure the enough intake of calories and protein and preventing the risk of intestinal bacterial translocation effectively. Endoscope-guided placement of feeding tubes is a kind of simple??direct and accurate method to establish enteral nutrition in clinic. The method has high success rate??relatively simple operation. Thus??it is a safe and effective treatment for enteral nutrition, which is worthy of clinical application.     

Multiple micronutrient supplementation cost–benefit tool for informing maternal nutrition policy and investment decisions

Antenatal multiple micronutrient supplementation (MMS) is an intervention that can help reach three of the six global nutrition targets, either directly or indirectly: a reduction in low birth weight, stunting, and anaemia in women of reproductive age. To support global guideline development and national decision-making on investments into maternal nutrition, Nutrition International developed a modelling tool called the MMS cost–benefit tool to help users understand whether antenatal MMS is better value for money than iron and folic acid supplementation (IFAS) during pregnancy. The MMS cost–benefit tool can generate estimates on the potential health impact, budget impact, economic value, cost-effectiveness and benefit–cost ratio of investing in MMS compared to IFAS in LMICs. In the 33 countries with data included in the tool, the MMS cost–benefit tool shows that transitioning is expected to generate substantial health benefits in terms of morbidity and mortality averted and can be very cost-effective in multiple scenarios for these countries. The cost per DALY averted averages at US$ 23.61 and benefit–cost ratio ranges from US$ 41–US$ 1304: $1.0, which suggest MMS is good value for money compared with IFAS. With its user-friendly design, open access availability, and online data-driven analytics, the MMS cost–benefit tool can be a powerful resource for governments and nutrition partners seeking timely and evidence-based analyses to inform policy-decision and investments towards the scale-up of MMS for pregnant women globally.     

早产儿早期应用静脉营养的研究进展

早产儿的营养问题是近年来新生儿科极为关注的问题.对于三大物质(葡萄糖、蛋白质及脂肪)的代谢及利用,早产儿有其自身的特点.经典的静脉营养方案为了避免其对早产儿产生的不良反应,都是循序渐进地给予脂肪乳及氨基酸,但易使早产儿处于营养缺乏状态.近几年的临床研究表明,生后24h内即给予早产儿足量的静脉营养液不仅为早产儿的生长发育提供了良好的能量基础,而且不会使早产儿出现相关并发症.