See “Optimizing Early Nutritional Support Based on Recent Recommendations in VLBW Infants Allows Abolishing Postnatal Growth Restriction” by Senterre and Rigo on page 536.
The ultimate goal in neonatology is to achieve a functional outcome in premature infants that is comparable with healthy term-born infants (1); however, many infants face detrimental effects from their early birth (2,3) Because nutrition is one of the key factors for normal cell growth, providing the right amount and quality of nutrients could prove pivotal for normal development. Many premature infants are catabolic during the first week of life, however, which has directly been linked to growth failure, disease, and suboptimal long-term outcome.
Many articles have been published showing that first-week nutritional management can result in positive nitrogen balance and thus growth of lean body mass. The article published in this issue of the Journal by Senterre and Rigo is the first to show that it is possible to provide adequate nutrition in the first few weeks of life during routine management (4). The results are excellent. The suboptimal growth pattern we have observed so frequently in many studies (5,6) is not shown here. Senterre and Rigo showed that after the initial drop in weight gain, infants remained within their growth trajectory.
This is an important step because nutrition has long been regarded as less important than, for example, ventilation strategies, usage of dopamine or dobutamine, or the choice for certain antibiotics. Such an attitude neglects the effect of appropriate nutrition on long-term outcome, even or maybe especially in ill infants (7). A few publications prospectively show a positive effect on outcome. The largest stems from the United Kingdom showing, for example, the direct effect of early nutrition on nucleus caudatus volume (8), whereas previously, the effect of early nutrition was shown on IQ (9). In addition, parenteral amino acid and energy intake during the first week of life seems to be related to cognitive development at 2 years of life (10). Although management aiming at the prevention of undernutrition in the neonatal intensive care unit seems logical, we also should be aware of the possibility that the quality of nutrients may not be optimal and may induce adverse effects in either the short or long term. Appropriate designed prospective nutritional intervention trials with a large number of infants are required. The endpoints should be neurocognitive development at 2 years or later in life, but they also should include other markers of long-term health such as body composition, lipid status, bone health, and blood pressure. Only with these endpoints can we show the pivotal role of early nutrition in these vulnerable infants.
1. Agostoni C, Buonocore G, Carnielli VP, et al. Enteral nutrient supply for preterm infants: commentary from the European Society of Paediatric Gastroenterology, Hepatology, and Nutrition Committee on Nutrition. J Pediatr Gastroenterol Nutr
2. Aarnoudse-Moens CS, Weisglas-Kuperus N, van Goudoever JB, et al. Meta-analysis of neurobehavioral outcomes in very preterm and/or very low birth weight children. Pediatrics
3. Weisglas-Kuperus N, Hille ET, Duivenvoorden HJ, et al. Intelligence of very preterm or very low birthweight infants in young adulthood. Arch Dis Child Fetal Neonatal Ed
4. Senterre T, Rigo J. Optimizing early nutritional support based on recent recommendations in VLBW infants allows abolishing postnatal growth restriction. J Pediatr Gastroenterol Nutr
5. Hulst J, Joosten K, Zimmermann L, et al. Malnutrition in critically ill children: from admission to 6 months after discharge. Clin Nutr
6. Ehrenkranz RA, Younes N, Lemons JA, et al. Longitudinal growth of hospitalized very low birth weight infants. Pediatrics
7. Ehrenkranz RA, Das A, Wrage LA, et al. Early nutrition mediates the influence of severity of illness on extremely LBW infants. Pediatr Res
8. Isaacs EB, Gadian DG, Sabatini S, et al. The effect of early human diet on caudate volumes and IQ. Pediatr Res
9. Lucas A, Morley R, Cole TJ. Randomised trial of early diet in preterm babies and later intelligence quotient. BMJ
10. Stephens BE, Walden RV, Gargus RA, et al. First-week protein and energy intakes are associated with 18-month developmental outcomes in extremely low birth weight infants. Pediatrics