- Email: [email protected]
Symposium Summary: Looking Back and Looking Forward
Symposium Summary: Looking Back and Looking Forward
C
urrent clinical practice is based on the application of the best-available knowledge. Nutritional guidelines for preterm infants were last updated in 2005. This symposium served to establish a global consensus and a firm scientific base for neonatal nutrition practices. We feel confident to present updated recommendations in the Table. In addition, small-for-gestational-age infants were identified to be a unique population. The following recommendations for this group are: (1) feed according to gestational age, with special consideration of supplements for iron and micronutrients; and (2) do not promote rapid weight gain and avoid excess fat gain because they increase the risk for metabolic syndrome in later life. As a group, we also agreed on the following statements: (1) There is no conclusive evidence to recommend the routine use of prebiotics, probiotics, and synbiotics in preterm infants. Although data supporting the use of specific probiotics in the case of necrotizing enterocolitis are encouraging, available trials to not permit a decision to be made on optimum strain, dose, or protocol of use; and (2) There are insufficient data to recommend the routine use of glutamine, arginine, nucleotides, omega-3 polyunsaturated fatty acids, and lactoferrin to improve host defenses in preterm infants. Although we know more than we did a decade ago, there is a great need for additional knowledge about what works best in practice and to explore new areas of interest. The following gaps in knowledge were identified.
Growth Improved reference standards for intrauterine and postnatal growth for each subpopulation of preterm infants that take short- and long-term outcomes into account need to be developed.
Biomarkers of zinc, copper, and vitamin A stores must be defined.
Prebiotics, Probiotics, and Synbiotics Tools used to assess the microbiome at birth and subsequent changes need to be identified. The optimal microbiome needs to be defined, and efforts should be made to preserve it or restore it, as indicated by research evidence.
Community Support The quality and quantity of education provided to pediatricians and parents who care for late preterm and post discharge infants need to be improved.
Human Milk It is widely appreciated that human milk provides the best nutrition for normal “healthy” term infants, but human milk may not meet the needs of all preterm infants. Human milk fortifiers for preterm infants at a variety of postnatal ages should be made available to infants who will benefit from them, given their special needs. Extremely-low-birth-weight infants cared for in settings where exclusive human milk feeding is used may not receive all the required nutrients. Strategies to meet their needs must be developed while efforts to support and promote exclusive breastfeeding for healthy infants are preserved. “Baby Friendly” hospital environment practices should be compatible with the need to best serve the nutritional requirements of these high risk infants.
Small-for-Gestational-Age Infants Protein and Energy Currently, protein delivery to the preterm infant does not meet the infant’s need for protein, given the extraordinarily rapid growth required to match intrauterine rates. We know that more protein is needed early in life and less is needed later in life when growth rate decreases. Strategies need to be developed that enable health care providers to define and deliver the appropriate amount of protein to each infant according to his/her individual need. The quality of protein required by preterm infants for optimal growth and development at various postnatal ages must be defined in more detail.
There is a need for improved algorithms to identify and triage preterm (early and late) and small-for-gestational-age infants at birth that require minimal resources and are adaptable to less-privileged community settings (eg, inexpensive and robust weighing scales). Bringing Science to the Bedside Extraordinary efforts are expended each year to make new scientific discoveries designed to improve nutrition for preterm infants. After validating new science as a basis for nutritional products, there is an equally important need to
Micronutrients Please see the Author Disclosures at the end of this article.
The optimal amounts of iron and vitamin D relative to somatic weight and gestational age need to be defined.
0022-3476/$ - see front matter. Copyright ª 2013 Mosby Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2012.11.061
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THE JOURNAL OF PEDIATRICS
www.jpeds.com
Vol. 162, No. 3, Suppl. 1
Table. Daily nutrient needs of groups of preterm infants
Energy, kcal/kg Protein, g/kg Calcium, mg/kg
Micropreterm, £29 weeks
Preterm, $29 and £34.0 weeks
Late preterm, 34-38 weeks
Postdischarge
Term, $38 weeks
120-140 3.5-4.5 120-180
110-130 3.5-4.2 120-160
110-130 3.0-3.6 70-140
105-125 2.8-3.2 100-120
90-110 1.5-2.3 80-100
quickly deliver new and effective solutions to preterm infants globally. Efforts must be made to improve: (1) partnerships between the industry and academia to better support the needs of all infants and children; (2) regulatory approval processes by which new knowledge leads to better products to meet the specific needs of these infants; (3) mutual understanding of all concerned parties (academicians, industry, and regulators) involved in creating and implementing new advances in specialty nutritional support, for low-birth-weight and very-low-birth-weight infants in a manner that does not compromise the use of human milk as the preferred mode of feeding normal infants; (4) the ability of the health care community to provide the context, support, and dissemination of new scientific discoveries; and (5) the manner in which new improvements are analyzed for safety, risks, and benefits. These tests must be conducted in settings that are representative of developing and developed countries. Key stakeholders, academia, health care professional associations, United Nations agencies, and industry representatives must be involved in these processes that consider the best interest of children as the first priority. It is clear that understanding the science of neonatal nutrition is not the final outcome; rather, it represents the beginning of a journey. If it is our expectation that our scientific knowledge will improve the well being of preterm infants, we must engage in activities that will facilitate translating it to practical application. We must consider that the overarching goal of the global neonatal community is reaching the great majority of low-birth-weight infants who presently have a high risk of death and disability from inadequate nutrition and care in the first weeks of life. Most of these infants are born in developing countries and account for nearly 50% of the 4 million deaths that occur annually in infants and
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young children. Most of these deaths are preventable; it is up to us to create the environment where we make neonatal care—especially good nutrition—an essential component of health investments at the local, national, and international levels. We have to start by declaring that the present situation is unacceptable and that all concerned parties must join forces in securing better opportunities for health, growth and mental development of all infants, especially those most vulnerable.
Author Disclosures Carol Lynn Berseth, MD, is the Medical Director for Global Innovation at Mead Johnson Nutrition. She organized and facilitated the Symposium on Nutrition of the Preterm Infant. Ricardo Uauy, MD, PhD, chaired the Symposium on Nutrition of the Preterm Infant. Mead Johnson Nutrition paid his travel expenses. He also received an honorarium to compensate his time for contributing to, organizing, and chairing the meeting and for his contribution to the final editing of the Supplement. C. B. wrote the first draft of this manuscript. n Carol Lynn Berseth, MD Mead Johnson Nutrition Evansville, IN Ricardo Uauy, MD, PhD INTA U of Chile and Neonatology Division Catholic University Santiago, Chile Reprint requests: Carol Lynn Berseth, MD, Department of Medical Affairs: Mead Johnson Nutrition, 2500 W Lloyd Expressway, Evansville, IN 47721. E-mail: [email protected]
C
urrent clinical practice is based on the application of the best-available knowledge. Nutritional guidelines for preterm infants were last updated in 2005. This symposium served to establish a global consensus and a firm scientific base for neonatal nutrition practices. We feel confident to present updated recommendations in the Table. In addition, small-for-gestational-age infants were identified to be a unique population. The following recommendations for this group are: (1) feed according to gestational age, with special consideration of supplements for iron and micronutrients; and (2) do not promote rapid weight gain and avoid excess fat gain because they increase the risk for metabolic syndrome in later life. As a group, we also agreed on the following statements: (1) There is no conclusive evidence to recommend the routine use of prebiotics, probiotics, and synbiotics in preterm infants. Although data supporting the use of specific probiotics in the case of necrotizing enterocolitis are encouraging, available trials to not permit a decision to be made on optimum strain, dose, or protocol of use; and (2) There are insufficient data to recommend the routine use of glutamine, arginine, nucleotides, omega-3 polyunsaturated fatty acids, and lactoferrin to improve host defenses in preterm infants. Although we know more than we did a decade ago, there is a great need for additional knowledge about what works best in practice and to explore new areas of interest. The following gaps in knowledge were identified.
Growth Improved reference standards for intrauterine and postnatal growth for each subpopulation of preterm infants that take short- and long-term outcomes into account need to be developed.
Biomarkers of zinc, copper, and vitamin A stores must be defined.
Prebiotics, Probiotics, and Synbiotics Tools used to assess the microbiome at birth and subsequent changes need to be identified. The optimal microbiome needs to be defined, and efforts should be made to preserve it or restore it, as indicated by research evidence.
Community Support The quality and quantity of education provided to pediatricians and parents who care for late preterm and post discharge infants need to be improved.
Human Milk It is widely appreciated that human milk provides the best nutrition for normal “healthy” term infants, but human milk may not meet the needs of all preterm infants. Human milk fortifiers for preterm infants at a variety of postnatal ages should be made available to infants who will benefit from them, given their special needs. Extremely-low-birth-weight infants cared for in settings where exclusive human milk feeding is used may not receive all the required nutrients. Strategies to meet their needs must be developed while efforts to support and promote exclusive breastfeeding for healthy infants are preserved. “Baby Friendly” hospital environment practices should be compatible with the need to best serve the nutritional requirements of these high risk infants.
Small-for-Gestational-Age Infants Protein and Energy Currently, protein delivery to the preterm infant does not meet the infant’s need for protein, given the extraordinarily rapid growth required to match intrauterine rates. We know that more protein is needed early in life and less is needed later in life when growth rate decreases. Strategies need to be developed that enable health care providers to define and deliver the appropriate amount of protein to each infant according to his/her individual need. The quality of protein required by preterm infants for optimal growth and development at various postnatal ages must be defined in more detail.
There is a need for improved algorithms to identify and triage preterm (early and late) and small-for-gestational-age infants at birth that require minimal resources and are adaptable to less-privileged community settings (eg, inexpensive and robust weighing scales). Bringing Science to the Bedside Extraordinary efforts are expended each year to make new scientific discoveries designed to improve nutrition for preterm infants. After validating new science as a basis for nutritional products, there is an equally important need to
Micronutrients Please see the Author Disclosures at the end of this article.
The optimal amounts of iron and vitamin D relative to somatic weight and gestational age need to be defined.
0022-3476/$ - see front matter. Copyright ª 2013 Mosby Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2012.11.061
S115
THE JOURNAL OF PEDIATRICS
www.jpeds.com
Vol. 162, No. 3, Suppl. 1
Table. Daily nutrient needs of groups of preterm infants
Energy, kcal/kg Protein, g/kg Calcium, mg/kg
Micropreterm, £29 weeks
Preterm, $29 and £34.0 weeks
Late preterm, 34-38 weeks
Postdischarge
Term, $38 weeks
120-140 3.5-4.5 120-180
110-130 3.5-4.2 120-160
110-130 3.0-3.6 70-140
105-125 2.8-3.2 100-120
90-110 1.5-2.3 80-100
quickly deliver new and effective solutions to preterm infants globally. Efforts must be made to improve: (1) partnerships between the industry and academia to better support the needs of all infants and children; (2) regulatory approval processes by which new knowledge leads to better products to meet the specific needs of these infants; (3) mutual understanding of all concerned parties (academicians, industry, and regulators) involved in creating and implementing new advances in specialty nutritional support, for low-birth-weight and very-low-birth-weight infants in a manner that does not compromise the use of human milk as the preferred mode of feeding normal infants; (4) the ability of the health care community to provide the context, support, and dissemination of new scientific discoveries; and (5) the manner in which new improvements are analyzed for safety, risks, and benefits. These tests must be conducted in settings that are representative of developing and developed countries. Key stakeholders, academia, health care professional associations, United Nations agencies, and industry representatives must be involved in these processes that consider the best interest of children as the first priority. It is clear that understanding the science of neonatal nutrition is not the final outcome; rather, it represents the beginning of a journey. If it is our expectation that our scientific knowledge will improve the well being of preterm infants, we must engage in activities that will facilitate translating it to practical application. We must consider that the overarching goal of the global neonatal community is reaching the great majority of low-birth-weight infants who presently have a high risk of death and disability from inadequate nutrition and care in the first weeks of life. Most of these infants are born in developing countries and account for nearly 50% of the 4 million deaths that occur annually in infants and
S116
young children. Most of these deaths are preventable; it is up to us to create the environment where we make neonatal care—especially good nutrition—an essential component of health investments at the local, national, and international levels. We have to start by declaring that the present situation is unacceptable and that all concerned parties must join forces in securing better opportunities for health, growth and mental development of all infants, especially those most vulnerable.
Author Disclosures Carol Lynn Berseth, MD, is the Medical Director for Global Innovation at Mead Johnson Nutrition. She organized and facilitated the Symposium on Nutrition of the Preterm Infant. Ricardo Uauy, MD, PhD, chaired the Symposium on Nutrition of the Preterm Infant. Mead Johnson Nutrition paid his travel expenses. He also received an honorarium to compensate his time for contributing to, organizing, and chairing the meeting and for his contribution to the final editing of the Supplement. C. B. wrote the first draft of this manuscript. n Carol Lynn Berseth, MD Mead Johnson Nutrition Evansville, IN Ricardo Uauy, MD, PhD INTA U of Chile and Neonatology Division Catholic University Santiago, Chile Reprint requests: Carol Lynn Berseth, MD, Department of Medical Affairs: Mead Johnson Nutrition, 2500 W Lloyd Expressway, Evansville, IN 47721. E-mail: [email protected]