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Background: Racial disparities in breastfeeding rates persist in the United States with Black women having the lowest rates of initiation and continuation. A literature review attributes this to ma...

Background Standardized parenteral nutrition (PN) formulations are used in at-risk neonates to provide nutrition immediately following birth. However, evidence for the optimal formulation(s) to maximize growth while reducing the risks of glucose and electrolyte abnormalities is limited. Purpose The purpose of this study was to compare the rates of hypernatremia and hyperglycemia with 2 weight-based standardized PN formulations versus one standard PN in low birth-weight preterm neonates. Methods This was a single-center observational study of infants less than 1800 g birth weight and less than 37 weeks' gestation who received standardized PN in the first 48 hours of life. Patients in the weight-based PN group were compared with a historical group of patients receiving single standard PN. Rates of hypernatremia and hyperglycemia were compared by χ2 analysis. Results There was a nonsignificant (P = .147) reduction in hypernatremia in the weight-based PN group (9 of 87; 10.3%) compared with the single PN group (16 of 89; 18.0%). However, hyperglycemia was significantly more frequent in the weight-based group than in the single PN group (24.1% vs 12.4%, P = .035). Implications for practice The 2 weight-based PN standardized formulations studied did not significantly decrease the incidence of hypernatremia or hyperglycemia. Implications for research Future studies to determine optimal standardized PN to provide early nutrition in high-risk neonates are warranted.

The purpose of this study was to determine whether a point-of-care osmotic device concentrates important human milk (HM) nutrients to support feeding neonates requiring high-nutrient, low-volume feedings. Raw and pasteurized HM samples were concentrated to determine the effects of time and temperature on concentration. Concentrated samples were compared with matched baseline samples to measure changes in selected nutrient concentrations. Furthermore, changes in concentration of certain bioactive components of raw milk samples were measured. The device significantly increased the concentrations of the majority of the measured nutrient and bioactive levels (p 30%. In all cases, the concentration rate of pasteurized HM was greater than that of raw HM. The osmotic concentration of HM is a promising option for neonatal nutrition. Further studies are needed to establish an evidence base for the practical applications of this point-of-care device.

This study reports on the human milk fortification session at the 2019 NEC Society Symposium, which included clinicians and parents discussing the evidence comparing fortification options such as efficacy, safety, cost effectiveness, and the need for parents to be informed about fortifier choice. With the current literature available and the varying standard of care practices for human milk fortification, further studies are needed to determine the most complete diet for preterm infants. The optimal diet would not only provide key nutrients and energy for growth and development, but also improve short- and long-term outcomes. Parents, as advocates and providers for their infant, should be informed, educated, and included in the discussion and decisions regarding fortification of human milk for their infant.

Background: Vitamin D supplementation is known to both prevent and treat rickets, a disease of hypomineralized bone. Childhood is a period of great bone development and, therefore, attention to the vitamin D needed to optimize bone health in childhood is imperative. Summary: Observational studies have pointed to a vitamin D status, as indicated by a 25-hydroxyvitamin D concentration, of 50 nmol/L to ensure avoidance of rickets and of 75 nmol/L to optimize health. However, the benefits of achieving these levels of vitamin D status are less evident when pediatric randomized, controlled trials are performed. In fact, no specific pediatric vitamin D supplementation has been established by the existing evidence. Yet, study of vitamin D physiology continues to uncover further potential benefits to vitamin D sufficiency. This disconnection between vitamin D function and trials of supplementation has led to new paths of investigation, including establishment of the best method to measure vitamin D status, examination of genetic variation in vitamin D metabolism, and consideration that vitamin D status is a marker of another variable, such as physical activity, and its association with bone health. Nevertheless, vitamin D supplementation in the range of 10–50 μg/day appears to be safe for children and remains a promising intervention that may yet be supported by clinical trials as a method to optimize pediatric health. Key Message: Pediatric vitamin D status is associated with avoidance of rickets. Randomized, controlled trials of vitamin D supplementation for pediatric bone health are limited and equivocal in their results. Beyond bone, decreased risk for autoimmune, infectious, and allergic diseases has been associated with higher vitamin D status. The specific vitamin D supplementation to optimize toddler, child, and adolescent outcomes is unknown, but doses 10–50 μg/day are safe and may be beneficial.

Objective This study aimed to determine the effect of elevated energy intake with medium-chain triglyceride (MCT) oil or formula powder on growth velocity and weight z-score in very low birth weight infants receiving human milk and human milk fortifier. Study Design This was a cohort study of infants exposed to MCT oil or formula powder for at least 7 days. Mean 7-day change in growth velocity and weight z-scores were compared pre- and postintervention. Results Forty-three infants received increased energy with either MCT oil or formula powder. Infants receiving MCT oil were more preterm and had a lower birth weight. When evaluating 7-day changes pre- and postintervention, growth velocity increased from 10.0 g/kg/day to 19.8 g/kg/day, and change in weight Z-score increased from –0.24 to 0.05. Conclusion This clinical approach using MCT oil or formula powder for additional energy was associated with improved, at least short-term, growth velocity and weight z-score trajectory.

Background: The safety of higher dose vitamin D (vitD) supplementation in women who change from exclusive or full breastfeeding to combination feeding or who continue supplementation after cessation of breastfeeding is unknown. Objective: Compare vitD supplementation safety of 6,400 to 400 IU/day and 2,400 IU/day using specific laboratory parameters in postpartum women and their infants through 7 months postpartum by feeding type. Design: In this randomized controlled trial, mothers (exclusively breastfeeding or formula-feeding) were randomized at 4–6 weeks' postpartum to 400, 2,400, or 6,400 IU vitD(3) (cholecalciferol)/day for 6 months. Breastfeeding infants in 400 IU group received oral 400 IU vitD(3)/day; infants in 2,400 and 6,400 IU groups received placebo. Maternal safety parameters (serum vitD, 25-hydroxy-vitamin D [25(OH)D; calcidiol], calcium, phosphorus, intact PTH; urinary calcium/creatinine ratios; and feeding type/changes) were measured monthly; infant parameters were measured at months 1, 4, and 7. Sufficiency was defined as 25(OH)D >50 nmol/L. Feeding type was defined as exclusive/full, combination, or formula-feeding. Data were analyzed using SAS 9.4. Results: Four hundred nineteen mother-infant pairs were randomized into the three treatment groups and followed: 346 breastfeeding and 73 formula-feeding pairs. A dose of 6400 IU/day safely and significantly increased maternal vitD and 25(OH)D from baseline in all mothers regardless of feeding type (p

The American Academy of Pediatrics recommends donor human milk (DHM) as the preferred feeding strategy for preterm infants when the milk of the mother is unavailable, based on conclusive evidence of lower rates of necrotizing enterocolitis with DHM feedings compared with preterm infant formula. The nutritional composition of DHM may differ from maternal milk for many reasons including differences in maternal characteristics, milk collection methods, and the impact of donor milk banking practices. The purpose of this systematic review is to examine the literature regarding research on the fat, protein, carbohydrate, vitamin, and mineral composition of DHM obtained through nonprofit milk banks or commercial entities. PubMed, CINAHL, and Scopus databases were searched for articles published between 1985 and 30 April, 2019. In total, 164 abstracts were screened independently by 2 investigators, and 14 studies met all inclusion criteria. Studies were predominantly small (

Critically ill neonates who require extracorporeal life support have particular nutrition needs. These infants require prescription of aggressive, early nutrition support by knowledge providers. Understanding the unique metabolic demands and nutrition requirements of these fragile patients is paramount, particularly if additional therapies such as aggressive diuretic regimens or continuous renal replacement therapy are used concurrently. Although the American Society for Parenteral and Enteral Nutrition has published guidelines for this population, a review of each nutrition component is warranted because few studies exist specific to this population. Long-term complications in survivors of neonatal extracorporeal life support, particularly in patients with select diagnoses such as congenital diaphragmatic hernia, can be significant and must be recognized and anticipated. This review focuses on recognizing the nutrition needs of neonatal patients requiring extracorporeal life support, appraising the available data to guide selection of an appropriate mode of nutrition delivery, and describing the anticipated long-term nutrition implications of extracorporeal life support provision during the neonatal period.

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols, free from commercial interest or influence, for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Adequate protein intake by very-low-birth-weight preterm infants (≤1,500 g at birth) is essential to optimize growth and development. The estimated needs for this population are the highest of all humans, however, the recommended intake has varied greatly over the past several years. A literature search was conducted in PubMed, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Cochrane Central databases to identify randomized controlled trials evaluating the effect of prescribed protein intake and identified outcomes. Articles were screened by 2 reviewers, risk of bias was assessed, data were synthesized quantitatively and narratively, and each outcome was separately graded for certainty of evidence. The literature search retrieved 25,384 articles and 2 trials were included in final analysis. No trials were identified that evaluated effect of protein amount on morbidities or mortality. Moderate certainty evidence found a significant difference in weight gain when protein intake of greater than 3.5 g/kg/day from preterm infant formula was compared with lower intakes. Low-certainty evidence found no evidence of effect of protein intake of 2.6 vs 3.1 vs 3.8 g/kg/day on length, head circumference, skinfold measurements, or mid-arm circumference. Low-certainty evidence found some improvement in development measures when higher protein intake of 3.8 vs 3.1 vs 2.6 g/kg/day were compared. Low-certainty evidence found no significant difference in bone mineral content when these protein intakes were compared. No studies were identified that compared protein intake greater than 4.0 g/kg/day. This systematic review found that protein intake between 3.5 and 4.0 g/kg/day promotes weight gain and improved development.

The mechanism through which developmental programming of offspring overweight/obesity following in utero exposure to maternal overweight/obesity operates is unknown but may operate through biologic pathways involving offspring anthropometry at birth. Thus, we sought to examine to what extent the association between in utero exposure to maternal overweight/obesity and childhood overweight/obesity is mediated by birth anthropometry. Analyses were conducted on a retrospective cohort with data obtained from one hospital system. A natural effects model framework was used to estimate the natural direct effect and natural indirect effect of birth anthropometry (weight, length, head circumference, ponderal index, and small-for-gestational age [SGA] or large-for-gestational age [LGA]) for the association between pre-pregnancy maternal body mass index (BMI) category (overweight/obese vs normal weight) and offspring overweight/obesity in childhood. Models were adjusted for maternal and child socio-demographics. Three thousand nine hundred and fifty mother–child dyads were included in analyses (1467 [57.8%] of mothers and 913 [34.4%] of children were overweight/obese). Results suggest that a small percentage of the effect of maternal pre-pregnancy BMI overweight/obesity on offspring overweight/obesity operated through offspring anthropometry at birth (weight: 15.5%, length: 5.2%, head circumference: 8.5%, ponderal index: 2.2%, SGA: 2.9%, and LGA: 4.2%). There was a small increase in the percentage mediated when gestational diabetes or hypertensive disorders were added to the models. Our study suggests that some measures of birth anthropometry mediate the association between maternal pre-pregnancy overweight/obesity and offspring overweight/obesity in childhood and that the size of this mediated effect is small.

Growth and nutrition in preterm infants have long-term implications for neurodevelopmental and cardiometabolic outcomes. Many infants are discharged from the neonatal intensive care unit (NICU) with growth restriction, but often without a specialized team to monitor postdischarge growth. At our institution, we addressed our ongoing concerns for the health and growth of these infants post-discharge by creating a Nutrition NICU Graduate Clinic. This clinic serves infants discharged from our NICU who were born with very low birth weight, had difficulty growing or feeding while inpatient, had a gastrostomy tube placed during hospitalization, or were deemed high risk for other reasons by our neonatal team, with the first clinic visit within 5 weeks of discharge. Data from our first 227 patients at time of discharge, first clinic visit, and any available second clinic visits are described. Anthropometrics show a high rate of extrauterine growth restriction at time of discharge with continued growth restriction at follow-up. Feeding regimens prescribed at discharge and variations from the prescribed regimen at time of follow-up are described. At time of first clinic visit, most patients (92.2%) required a medical or dietary intervention by our team. Our findings illustrate the need for early and specialized nutrition follow-up in this patient population to improve growth trajectory post-discharge.

OBJECTIVE Identify whether an enteral nutrition goal of reaching full feeds by 7 postnatal days for infants 1-1.5 kg and by 14 postnatal days for infants

Preterm infants are increasingly diagnosed as having "extrauterine growth restriction" (EUGR) or "postnatal growth failure" (PGF). Usually EUGR/PGF is diagnosed when weight is

Introduction: The health benefits of breastfeeding for both the mother and her offspring are well established, and breastfeeding may be especially important for mitigating negative health effects of pregnancy complicated by diabetes. Objective: This study sought to examine the association between race/ethnicity, maternal diabetes, and breastfeeding initiation in South Carolina (SC). Materials and Methods: Our study population is comprised of all live, singleton, full-term births in SC delivered January 2004 to December 2016 (292,468 non-Hispanic Whites, 173,158 non-Hispanic Blacks, and 52,174 Hispanics). Generalized estimating equations and an interaction term between race/ethnicity and maternal diabetes status were used to estimate the race/ethnic-specific odds ratio (OR) and 95% confidence intervals (CIs) that a mother with diabetes versus without diabetes initiated breastfeeding. Models were adjusted for maternal and infant sociodemographics (Model 1), additionally for clinical variables and birth outcomes (Model 2), and also for maternal prepregnancy body mass index (BMI) (Model 3). Results: We found statistically significant differences in breastfeeding initiation by race/ethnicity and diabetes status in Model 1. These associations were attenuated and lost significance upon additional adjustment. Non-Hispanic Black mothers with gestational diabetes were significantly more likely to initiate breastfeeding than nondiabetic non-Hispanic Black mothers, even after adjustment for prepregnancy BMI (OR: 1.07 [95% CI 1.02-1.12]). Conclusion: This large, population-based study of all live, singleton, full-term births in SC improves our understanding of how race/ethnicity and maternal metabolic disorders impact breastfeeding initiation, and may inform future hospital-based breastfeeding interventions in populations with the most need.

Human milk provides not only ideal nutrition for infant development but also immunologic factors to protect from infection and inflammation. For the newborn preterm infant, the natural delivery of milk is not attainable, and instead pumped maternal milk, donor human milk, and human milk fortification are mainstays of clinical care. Current research demonstrates a decreased risk of necrotizing enterocolitis with maternal milk and donor human milk when individually compared to formula and with a complete human milk diet of maternal milk supplemented with donor human milk. The incidence of severe retinopathy of prematurity is decreased with an exclusive human milk diet, and this decrease is more pronounced with human milk-based compared to bovine milk-based human milk fortifier. The incidence of other morbidities such as late-onset sepsis and bronchopulmonary dysplasia is decreased with higher dose of human milk though significant differences are not apparent in exclusive human milk diet studies.

Gestational diabetes mellitus (GDM) is a disease of glucose intolerance during pregnancy and is associated with infant macrosomia, infant hypoglycemia, and increased risk of type 2 diabetes development for both mother and infant. Although breastfeeding potentially mitigates metabolic sequelae for both mother and her offspring, women with GDM are more likely to introduce formula and, therefore, are less likely to exclusively breastfeed, and some studies show less initiation and shorter breastfeeding duration as well. Therefore, women with GDM and their infants warrant investigation of methods by which to increase breastfeeding exclusivity and duration. Exploration of the barriers to breastfeeding for women with GDM demonstrate not only biologic complications such as maternal obesity, increased prevalence of cesarean section, and infant hypoglycemia, but also maternal report of less provider support of breastfeeding and reduced breastfeeding self-efficacy. Consequently, interventions designed to optimize breastfeeding outcomes in this high-risk population should not only focus on the biology but also on provider behavior and maternal social factors.

Late preterm infants (LPIs) have specific vulnerabilities and increased risk for breastfeeding difficulties and hospital readmission, particularly within the first 2 weeks after birth. Breastfeeding the LPI can present multiple challenges for parents, nurses, lactation consultants (LCs), and healthcare providers (HCPs), including physiological instability (hypothermia, hypoglycemia, respiratory distress, and excessive or extended jaundice) and feeding immaturities (weak, ineffective, and uncoordinated suck and swallow patterns, fatigue with feedings, increased sleepiness, ineffective latch, and inadequate milk transfer), along with difficulty establishing maternal milk supply. These challenges warrant awareness, discussion, and tailored interventions to increase breastfeeding success and to decrease LPI feeding-related morbidity and rehospitalization. This chapter will include suggestions for managing breastfeeding difficulties for parents of LPIs and HCPs in both the postpartum hospital environment and home or community.

OBJECTIVE: Compare effectiveness of maternal vitamin D3 supplementation with 6400 IU per day alone to maternal and infant supplementation with 400 IU per day. METHODS: Exclusively lactating women living in Charleston, SC, or Rochester, NY, at 4 to 6 weeks postpartum were randomized to either 400, 2400, or 6400 IU vitamin D3/day for 6 months. Breastfeeding infants in 400 IU group received oral 400 IU vitamin D3/day; infants in 2400 and 6400 IU groups received 0 IU/day (placebo). Vitamin D deficiency was defined as 25-hydroxy-vitamin D (25(OH)D) RESULTS: Of the 334 mother-infant pairs in 400 IU and 6400 IU groups at enrollment, 216 (64.7%) were still breastfeeding at visit 1; 148 (44.3%) continued full breastfeeding to 4 months and 95 (28.4%) to 7 months. Vitamin D deficiency in breastfeeding infants was greatly affected by race. Compared with 400 IU vitamin D3 per day, 6400 IU/day safely and significantly increased maternal vitamin D and 25(OH)D from baseline (P < .0001). Compared with breastfeeding infant 25(OH)D in the 400 IU group receiving supplement, infants in the 6400 IU group whose mothers only received supplement did not differ. CONCLUSIONS: Maternal vitamin D supplementation with 6400 IU/day safely supplies breast milk with adequate vitamin D to satisfy her nursing infant’s requirement and offers an alternate strategy to direct infant supplementation.

OBJECTIVE: To identify the vitamin D status to optimize calcium and bone health in preterm infants. STUDY DESIGN: Very low birth weight infants had measurement of 25-hydroxyvitamin D status and markers of calcium and bone health from birth to term age. Piecewise linear regression modeling was performed to identify a 25-hydroxyvitamin D threshold associated with stable parathyroid hormone concentration and bone mineralization. RESULTS: In a cohort of 89 infants at term age, femur BMC and density increased linearly with 25-hydroxyvitamin D status until reaching a threshold of 48 ng/mL and 46 ng/mL, respectively. Parathyroid hormone status decreased as vitamin D status increased until reaching a plateau at 25-hydroxyvitamin D of 42 ng/mL. CONCLUSION: Preterm infant vitamin D status was significantly associated with PTH status and femur mineralization with suggestion that achieving a specific 25-hydroxyvitamin concentration is associated with optimal calcium homeostasis and femur bone mineralization.

Debate exists about when to initiate enteral feeding (EF) in very low birth weight (VLBW) preterm infants. This retrospective study compared the effectiveness of an education-based quality improvement project and the relationship of time of the first EF to necrotizing enterocolitis (NEC) or death incidence and parenteral nutrition (PN) days in VLBW infants.VLBW infants born in 2 epochs were compared for hour of the first feed, PN days, NEC or death incidence, and feeding type. The 2 epochs were temporally divided by a quality improvement initiative to standardize initiation of EF in postnatal hours 6-24.603 VLBW infants were included. Median time of feed initiation decreased from 33 (Epoch 1) to 14h (Epoch 2) (p0.0001). Median PN days were 14 vs. 12, respectively (p=0.07). The incidence of NEC or death was 13.4% vs. 9.5%, respectively (p=0.14). When controlling for birth weight, gestational age, race, gender, and time period, earlier feed initiation was associated with decreased NEC or death (p=0.003). Evaluation of the relationship of early EF (defined as within the first 24h) in Epoch 2 alone showed that early EF was significantly associated with decreased NEC or death (6.3 vs 15.1%) (RR, 95% CI=0.28, 0.13-0.58) and less PN days (p0.0001).In a VLBW infant cohort, an education-based process improvement initiative decreased time of EF initiation to a median of 14h with no associated increase in NEC or death. In fact, results suggest that earlier feeding is associated with decreased NEC or death.

To determine the incidence of vitamin D deficiency in neonates with congenital heart disease and whether differences exist by race. In addition, we determined the effect of cardiopulmonary bypass on vitamin D levels and explored associations between 25-hydroxyvitamin D [25(OH)D] levels and postoperative outcomes.We performed a secondary analysis of a prospective randomized controlled trial in 70 neonates undergoing cardiac surgery. The neonates' 25(OH)D levels were measured in the operating room before skin incision (baseline), at the cessation of cardiopulmonary bypass, and at 24 hours postoperatively. Associations between these levels and clinical outcomes were explored. Vitamin D deficiency was defined as a 25(OH)D level20 ng/mL.Vitamin D deficiency was present in 84% (59/70); concentrations in African Americans (n = 20) were significantly lower than those of Caucasian/other race/ethnicity (n = 50) (10.2 ± 4.2 vs 16.0 ± 5.6 ng/mL, P .0001). The 24-hour postoperative 25(OH)D levels were not different from baseline and correlated with a reduced postoperative inotropic requirement (r = -0.316, P = .008).Vitamin D deficiency is prevalent in neonates with congenital cardiac defects, and lower postoperative 25(OH)D levels are associated with the need for increased inotropic support in neonates undergoing cardiac operations. These findings support that vitamin D deficiency may play a role in myocardial injury and postoperative recovery and warrants further investigation.

Determine the incidence of refeeding syndrome, defined by the presence of hypophosphatemia in very-low-birth-weight (VLBW) infants with intrauterine growth restriction (IUGR) compared with those without IUGR. In this retrospective cohort study, VLBW infants admitted over a 10-year period (271 IUGR and 1982 non-IUGR) were evaluated for specific electrolyte abnormalities in the first postnatal week. IUGR infants were significantly more likely to have hypophosphatemia (41% vs 8.9%, relative risk (95% confidence interval: 7.25 (5.45, 9.65)) and severe hypophosphatemia (11.4% vs 1%, 12.06 (6.82, 21.33)) in the first postnatal week. The incidence of hypophosphatemia was significantly associated with the presence of maternal preeclampsia in all VLBW infants (odds ratio (OR): 2.58 (1.96, 3.40)) when controlling for birth weight and gestational age. Refeeding syndrome occurs in VLBW infants with IUGR and born to mothers with preeclampsia. Close monitoring of electrolytes, especially phosphorus, is warranted in this population.

Background: The effect of latitude on maternal and infant vitamin D status during lactation is presumed to be strongly associated with higher rates of deficiency in those living at higher latitudes, yet with lifestyle changes, this conclusion may no longer be correct. Objective: To ascertain if higher latitude adversely affects the vitamin D status of lactating women and their fully breastfeeding infants. Study Design/Methods: Fully breastfeeding women and their infants were eligible for participation in this study as part of a larger prospective vitamin D supplementation trial. Women were recruited from two sites of differing latitude: Charleston, SC at 32˚N and Rochester, NY at latitude 43˚N. Maternal and infant baseline vitamin D status, intact parathyroid hormone (IPTH), serum calcium and phosphorus as a function of site/latitude were measured. The primary outcome was maternal and infant total circulating 25(OH)D at baseline by center/latitude, and the secondary outcome was the percent of women and infants who had achieved a baseline concentration of at least 20 ng/mL, meeting the Institute of Medicine’s definition of sufficiency at 4 to 6 weeks postpartum. Statistical analysis was performed using SAS version 9.3. Results: Higher latitude adversely affected vitamin D status only in lactating Caucasian women. African American and Hispanic women and infants living in Rochester compared to Charleston had improved vitamin D status, an effect that was no longer significant when controlling for socioeconomic factors and season. Overall, there was a significant vitamin D deficiency at baseline in lactating mothers, and a far greater deficiency in their infants. Maternal baseline 25(OH)D concentration remained positively associated with being Caucasian, BMI and summer months. Breastfeeding infant vitamin D status mirrored maternal status and remained positively associated with being Caucasian and summer months. Those infants who had been on a vitamin D supplement at the time of enrollment in the study had markedly improved vitamin D status compared to those infants not on supplement, but represented a significant minority of the cohort. Conclusions: There was a significant vitamin D deficiency among a cohort of women and their infants living at two diverse latitudes—Charleston, SC and Rochester, NY. Given the higher rate of vitamin D deficiency among African American and Hispanic women and their infants living at a lower latitude, conclusions about vitamin D status based on latitude alone may be faulty.

BACKGROUND Body composition is a key metric for assessing nutrition in preterm infants. In many neonatal intensive care units body composition is estimated using anthropometric indices which mathematically combine body weight and length. However, the accuracy of these indices is unknown in preterm infants. In contrast, air-displacement plethysmography (ADP) has been shown to accurately measure neonatal fat mass, but it is not widely available. OBJECTIVE The aim was to determine which anthropometric index is most correlated to infant fat mass, as determined by ADP. DESIGN We performed a retrospective observational study, comparing ADP-determined percent body fat at 366 time points for 239 preterm infants (born

Studies were examined to evaluate the impact of the Baby-Friendly Hospital Initiative (BFHI) on breastfeeding and early infant health outcomes in U.S. populations. Using the Social Ecological Model as a guiding theoretical framework, results were categorized into four interrelated multilevel factors: (1) maternal/infant dyad factors, (2) provider factors, (3) hospital organizational factors, and (4) policy/systems factors. Results from the review support the BFHI's success in facilitating successful breastfeeding initiation and exclusivity. Breastfeeding duration also appears to increase when mothers have increased exposure to Baby-Friendly practices, but deficiencies in breastfeeding tracking mechanisms have limited reliable breastfeeding duration data. Of the 10 steps of the BFHI, step 3, prenatal education and step 10, postnatal breastfeeding support are the most difficult steps to implement; however, those steps have the potential to significantly impact maternal breastfeeding decisions. The underlying mechanisms by which Baby-Friendly practices contribute to maternal breastfeeding decisions remain unclear; thus, studies are needed to examine mothers' experiences and perceptions of Baby-Friendly practices. Additionally, studies are needed to investigate the impact of the BFHI for women living in rural areas and in southeastern regions of the United States. Finally, studies are needed to examine early infant health outcomes related to the BFHI, especially for late premature infants (34–36 weeks) who are most vulnerable to poor outcomes and are in need of specialized breastfeeding support. Results from future qualitative and quantitative explorations could clarify how the delivery of Baby-Friendly practices leads to successful breastfeeding and infant health outcomes.

Pregnancy is a critical time in the lifecycle of a woman where she is responsible not only for her own well-being, but also that of her developing fetus, a process that continues during lactation. Until recently, the impact of vitamin D status during this period had not been fully appreciated. Data regarding the importance of vitamin D in health have emerged to challenge traditional dogma, anD'suggest that vitamin D – through its effect on immune function anD'surveillance – plays a role beyond calcium and bone metabolism on the health status of both the mother and her fetus. Following birth, this process persists; the lactating mother continues to be the main source of vitamin D for her infant. Thus, during both pregnancy and lactation, maternal deficiency predicts fetal and infant deficiency; the significance of this is just beginning to be understood and will be highlighted in this review.

Compare customized versus population-based growth curves for identification of small-for-gestational-age (SGA) and body fat percent (BF%) among preterm infants.Prospective cohort study of 204 preterm infants classified as SGA or appropriate-for-gestational-age (AGA) by population-based and customized growth curves. BF% was determined by air-displacement plethysmography. Differences between groups were compared using bivariable and multivariable linear and logistic regression analyses.Customized curves reclassified 30% of the preterm infants as SGA. SGA infants identified by customized method only had significantly lower BF% (13.8 ± 6.0) than the AGA (16.2 ± 6.3, p = 0.02) infants and similar to the SGA infants classified by both methods (14.6 ± 6.7, p = 0.51). Customized growth curves were a significant predictor of BF% (p = 0.02), whereas population-based growth curves were not a significant independent predictor of BF% (p = 0.50) at term corrected gestational age.Customized growth potential improves the differentiation of SGA infants and low BF% compared with a standard population-based growth curve among a cohort of preterm infants.

Despite its discovery a hundred years ago, vitamin D has emerged as one of the most controversial nutrients and prohormones of the 21st century. Its role in calcium metabolism and bone health is undisputed but its role in immune function and long-term health is debated. There are clear indicators from in vitro and animal in vivo studies that point to vitamin D’s indisputable role in both innate and adaptive immunity; however, the translation of these findings to clinical practice, including the care of the pregnant woman, has not occurred. Until recently, there has been a paucity of data from randomized controlled trials to establish clear cut beneficial effects of vitamin D supplementation during pregnancy. An overview of vitamin metabolism, states of deficiency, and the results of recent clinical trials conducted in the U.S. are presented with an emphasis on what is known and what questions remain to be answered.

Historically, in very low-birth-weight infant care, nutritional support was delayed during the first postnatal days because of fear of toxicity and harm with immature metabolic systems and intestinal function. Recent evidence demonstrates that early nutritional support is not only safe but likely necessary to optimize infant growth and neurodevelopment. In fact, nutrition management is a critical factor in very low-birth-weight infant golden hour support. Contemporary studies in protein and lipid intravenous support and early feeds as minimal enteral nutrition exhibit safety and some efficacy. We will present analysis of this evidence and development of potential better practices on the basis of these data as well as a review of golden hour fluid and glucose management. In addition, we provide several outcomes following our adoption of potentially better golden hour nutrition practices.

The 2008 revised American Academy of Pediatrics (AAP) recommendation for 400 IU/day vitamin D intake makes progress toward achieving infant vitamin D sufficiency in the United States. Further study, however, is needed both to define vitamin D sufficiency for preterm infants based on markers of vitamin D biologic function and to develop supplementation strategies to ensure adequate vitamin D intake and, thus, vitamin D sufficiency in this at-risk population. In this review, we highlight some of the issues surrounding vitamin D status of the neonate and the particular risks for the preterm infant. We review the evidence regarding the impact of vitamin D deficiency in this population and the safety and efficacy of vitamin D supplementation. Based on previous study in preterm infants, the current AAP guidelines to achieve serum 25-hydroxyvitamin D [25(OH)D] status of at least 50 nmol/L and to receive at least 400 IU/day are safe and possibly adequate. Because of the nutritional difficulties in achieving consistent delivery of 400 IU/day of vitamin D in the preterm infant, it is imperative to devise strategies for close monitoring of each preterm infant's vitamin D status and consider oral vitamin D supplementation as an important adjunct to dietary sources and multivitamin preparations.

Extracardiac or genetic abnormalities (EGA) represent a factor in the morbidity of patients with congenital heart disease. We evaluated the way neonates with CHD are screened at our institution and determined the yield for the screening tests. We reviewed the charts of 223 neonates with structural CHD. Subjects were categorized into 6 groups: univentricular, left-sided obstructive lesions, right-sided obstructive lesions, septal defects, conotruncal defects (CTD), and other. We reviewed which patients underwent cranial ultrasonogram (CUS), abdominal ultrasonogram (AUS), and/or genetic studies (GS) as well as their results. There was a high prevalence of EGA in each group by CUS (32% to 42%), AUS (32% to 69%), and GS (10% to 60%). There was considerable variability in the proportion within each group that underwent screening tests, and the consistency of screening often was not congruent with the likelihood of abnormal results. Approximately 50% of our patients had ≥1 EGA identified, resulting in a cost-yield ratio of $4,508/patient with EGA. Screening for EGA at our institution is not uniform and is often at odds with the prevalence of such patients. Given the high prevalence of EGA, we advocate for a universal screening program for neonates with CHD using cranial/abdominal ultrasonography and genetic testing.

How human milk as the ideal infant nutrition lacks vitamin D activity leading to the severe bony deformities and muscle weakness of rickets has stymied scientists and clinicians for centuries. Recent understanding of human vitamin D requirements based on functional indicators of vitamin D activity demonstrate that the majority of humans, including lactating mothers, subsist in a vitamin D insufficient state. In this state, human milk provides inadequate vitamin D supply to the nursing infant. In contrast, with achieving maternal vitamin D sufficiency, human milk attains vitamin D activity equivalent to present infant oral supplementation. Current investigation of the role of vitamin D in diseases beyond bone health is revealing the significance of early life vitamin D sufficiency in establishing lifelong health.

Mothers of hospitalized premature infants who choose to provide breast milk are at increased risk of an inadequate breast milk supply. When nonpharmacologic interventions to increase milk supply fail, clinicians are faced with limited options. There is no current evidence to support the use of herbal galactogogues in this population and a black box warning for metoclopramide for potential serious side effects. Thus, domperidone was the only known, effective option for treatment of low milk supply in this population. With a thorough review of the literature on domperidone and coordination with the obstetrical, neonatal, lactation, and pharmacology teams, a domperidone treatment protocol for mothers of hospitalized premature infants with insufficient milk supply was developed at our institution and is presented in this article. A comprehensive understanding of domperidone for use as a galactogogue with a standard treatment protocol will facilitate safer prescribing practices and minimize potential adverse reactions in mothers and their hospitalized premature infants.

Despite the higher prevalence of vitamin D deficiency in blacks, the vitamin D status of black preterm infants remains unknown. In addition, with the combination of parenteral and enteral nutritional support that preterm infants receive, the effect of vitamin D-deficient breast milk on vitamin D status is unknown.To evaluate vitamin D status of preterm infants through the first month after delivery and compare status by race and feeding type.Thirty-six (36) preterm (or =32 weeks gestation) infants (19 black, 17 white) had assessment of feeding type, vitamin D intake, and serum 25-hydroxyvitamin D [25(OH)D] as a marker of vitamin D status at three time points in the first month after delivery.Black infants had a significantly lower mean 25(OH)D level on day 7-8 and day 14-15 evaluations than white infants [14.9 +/- 6.6 versus 23.3 +/- 9.3 ng/mL (p = 0.021) and 18.3 +/- 7.3 versus 25.6 +/- 10.3 ng/mL (p = 0.048), respectively], but the difference was no longer significant by day 28-30 evaluation [19.6 +/- 7.7 versus 26.2 +/- 11.6 ng/mL (p = 0.26)]. Vitamin D status was not significantly lower in infants receiving predominantly breast milk (p = 0.6). Vitamin D intake rose through the month as the amount and caloric density of enteral nutrition increased. Six infants had significant decrease in serum 25(OH)D values from day 14-15 to day 28-30 evaluation despite receiving400 IU/day vitamin D.Differences in vitamin D status occurred between black and white infants and were significant through the first 2 weeks after delivery. Infants receiving predominantly breast milk did not have significantly worse vitamin D status than those receiving formula. The significant decline in serum 25(OH)D status observed in 28% of the infants was not related to breast milk intake.

Improve vitamin D status in lactating women and their recipient infants, and measure breast milk calcium concentration [Ca] as a function of vitamin D regimen.Fully breastfeeding mothers were randomized at 1 month postpartum to 2000 (n = 12) or 4000 (n = 13) IU/day vitamin D for 3 months to achieve optimal vitamin D status [serum 25(OH)Dor =32 ng/mL (80 nmol/L)]. Breast milk [Ca], maternal and infant serum 25(OH)D and serum Ca, and maternal urinary Ca/Cr ratio were measured monthly.Mothers were similar between groups for age, race, gestation, and birth weight. 25(OH)D increased from 1 to 4 months in both groups (mean +/- SD): +11.5 +/- 2.3 ng/mL for group 2000 (p = 0.002) and +14.4 +/- 3.0 ng/mL for group 4000 (p = 0.0008). The 4000 IU/day regimen was more effective in raising both maternal and infant serum levels and breast milk antirachitic activity than the 2000 IU/day regimen. Breast milk [Ca] fell with continued lactation through 4 months in the 2000 and 4000 IU groups. Decline in breast milk [Ca] was not associated with vitamin D dose (p = 0.73) or maternal 25(OH)D (p = 0.94). No mother or infant experienced vitamin D-related adverse events, and all laboratory parameters remained in the normal range.High-dose vitamin D was effective in increasing 25(OH)D levels in fully breastfeeding mothers to optimal levels without evidence of toxicity. Breast milk [Ca] and its decline in both groups during 1 to 4 months were independent of maternal vitamin D status and regimen. Both the mother and her infant attained improved vitamin D status and maintained normal [Ca].

BACKGROUND: The objective of this study was to investigate whether a respiratory care bundle, implemented through participation in the Vermont Oxford Network-sponsored Neonatal Intensive Care Quality Improvement Collaborative (NIC/Q 2005) and primarily dependent on bedside caregivers, resulted in sustained decrease in the incidence of bronchopulmonary dysplasia (BPD) in infants < 30 wk gestation. METHODS: A retrospective cohort study was conducted. Infants inborn between 23 wk and 29 wk + 6 d of gestation were included. Patients with congenital heart disease, significant congenital or lung anomalies, or death before intubation were excluded. Four time periods (T1–T4) were identified: T1: September 1, 2002 to August 31, 2004; T2: September 1, 2004 to August 31, 2006; T3: September 1, 2006 to August 31, 2008; T4: September 1, 2008 to August 31, 2010. RESULTS: A total of 1,050 infants were included in the study. BPD decreased significantly in T3 post-implementation of the respiratory bundle compared with T1 (29.9% vs 51.2%, respectively; adjusted odds ratio [aOR] = 0.06 [95% CI 0.03–0.13], P = < .001). The decrease was not sustained into T4. There was a significant increase in the rate of BPD-free survival to discharge in T3 compared with T1 (53.1% vs 47%; aOR = 1.68 [95% CI 1.11–2.56], P = .01) that was also not sustained. The rate of infants requiring O2 at 28 d of life decreased significantly in T3 versus T1 (40.3% vs 69.9%, respectively; aOR = 0.12 [95% CI 0.07–0.20], P = < .001). Increases in the rate of surfactant administration by 1 h of life and rate of caffeine use were observed in T4 versus T1, respectively. There was a significant decrease in median ventilator days and a significant increase in the median number of noninvasive CPAP days throughout the study period. CONCLUSIONS: In this study, implementation of a respiratory bundle managed primarily by nurses and respiratory therapists was successful in increasing the use of less invasive respiratory support in a consistent manner among very low birthweight infants at a single institution. However, this study and others have failed to show sustained improvement in the incidence of BPD despite sustained process change.

Hospitals that set forth to obtain Baby-Friendly Hospital designation often face considerable challenges in implementing the purchase of formula and supplies at a fair market rate as outlined in the International Code of Marketing of Breast-milk Substitutes. Some of the challenges include difficulty tracking products in use and volumes used and obtaining pricing information from manufacturers of artificial milk. We report on our experience with assessing these factors, with an example of calculations used to arrive at fair market pricing, which might benefit other institutions seeking Baby-Friendly Hospital designation.

Objective: To evaluate whether infants receiving a supplemental 400 IU/day above standard preterm infant vitamin D (vitD) supplementation differed in mineral and bone health from infants receiving placebo. Methods: Very low birth weight (VLBW) infants with plasma 25-hydroxyvitamin D [25(OH)D] < 20 ng/ml (vitD deficiency) were enrolled within 3 days of birth and randomized to active (400 IU/day supplemental vitD) or placebo group until term age equivalent (TAE). At TAE, plasma 25(OH)D, parathyroid hormone (PTH), calcium, phosphorus, urinary calcium and phosphorus excretion, and femur and spine bone mineral content (BMC) and bone mineral density (BMD) were measured. Statistical analysis was by Chi-square, Fisher exact, and Wilcoxon Rank Sum. Results: Thirty-eight (19 each group) vitD-deficient infants were enrolled and followed at TAE. Active and control groups did not significantly differ in gender, race, birth gestational age, days from birth to TAE visit, or 25(OH)D at entry (13.6 and 11.8 ng/ml). From b...

Preterm birth necessitates that fetal organ development occur in the extra-uterine environment. This circumstance poses significant risk for gastrointestinal (GI) system development as this system doubles in length from 25 to 40 weeks’ gestation. The most severe consequence of preterm intestinal development is necrotizing enterocolitis (NEC)—an inflammatory cascade that leads to ischemia/necrosis of the intestines. This disease is found in 7–10 % of very low birth weight (VLBW) infants and is associated with 33 % mortality and 33 % long-term GI and/or neurodevelopmental morbidity. The two protective factors consistently identified to decrease risk for NEC are prolonged gestation and human milk feeds. Investigation into the mechanism of NEC has dominated the study of preterm infant intestinal development. Within this context, intestinal maturation and specifically intestinal permeability have been studied for 20 years.

Objective. To examine the effectiveness of oral vitamin (400 IU) supplementation on the nutritional vitamin D status of breastfeeding infants.Design. As part of a larger ongoing vitamin D RCT trial of lactating women, infants of mothers assigned to control received 1 drop of 400 IU vitamin /day starting at one month of age. Infant 25(OH)D levels (mean S.D.) were measured by RIA at visits 1, 4, and 7.Results. The infant mean S.D. 25(OH)D at baseline was 16.0 9.3 ng/mL (range 1.0–40.8; ); 24 (72.7%) had baseline levels Conclusions. Oral vitamin supplementation as an oil emulsion was associated with significant and sustained increases in 25(OH)D from baseline in fully breastfeeding infants through 7 months.

Except for degree of prematurity, risk factors for the development of necrotizing enterocolitis (NEC) in very low birth weight (VLBW) infant have not been consistently identified. In addition, fear of NEC determines the majority of VLBW infant feeding regimens in the first postnatal month. About 10-12% of infants weighing less than 1500 grams at birth will develop NEC and about one-third of them will die from the disease. Improved identification of preterm infants at risk for NEC could allow improved infant feeding to focus on growth and nutrition for infants at low-risk of NEC. The objective of this study was to develop an algorithm using artificial neural networks (ANN) to predict prematurely born infants at highest risk of NEC. The majority of ANN's considered optimal used small numbers of variables: 54% used a single variable, 30% used 2 variables, 12% used 3 variables and only 4% used 4 or 5 variables to predict NEC. Sixty-eight percent of the variables were selected first and 79% were selected as second variable at least once. Small for gestational age (SGA) and being artificially ventilated (ventilation: yes/no) were chosen first and second most often among all 57 variables. ANNs as predictive tools provide a first indication for the relative importance of the 57 variables in final decision-making.

Intestinal permeability in preterm infants represents a critical balance between absorption of nutritional agents and protection from dangerous pathogens. This study identified the relationship between feeding type (human milk and formula) and intestinal permeability as measured by lactulose to mannitol ratio in preterm infants in the first postnatal month.Sixty-two preterm (or=32 weeks of gestation) infants had assessment of feeding type and evaluation with enteral lactulose and mannitol administration and urinary measurement at three time points in the first postnatal month.Infants who received the majority of feeding as human milk (75%) demonstrated significantly lower intestinal permeability when compared to infants receiving minimal or no human milk (25% or none) at postnatal days 7, 14, and 30 (p = 0.02, 0.02, and 0.047, respectively). When infants receiving any human milk were compared to infants receiving formula only, a significant difference existed at day 7 and day 14 but not for day 30 (p = 0.04, 0.02, and 0.15, respectively). With evaluation over the complete study period, exclusively formula-fed infants demonstrated a 2.8-fold higher composite median lactulose/mannitol ratio when compared with those who received any human milk. Infants who received75% of enteral feeding as mother's milk demonstrated a 3.8-fold lower composite median ratio when compared to infants receiving25% or no mother's milk.Preterm infant intestinal permeability was significantly decreased for those receiving human milk versus formula in a dose-related manner in the first postnatal month.