EBNEO COMMENTARY: NUTRITIONAL SUPPORT FOR MODERATE-TO-LATE-PRETERM INFANTS

[EBNEO]

Tristan Dear and Jane Stremming from USA review EbNeo April 2024 Article of the Month: Alexander T, Asadi S, Meyer M, Harding JE, Jiang Y, Alsweiler JM, et al. Nutritional Support for Moderate-to-Late–Preterm Infants — A Randomized Trial. N Engl J Med. 2024;390:1493–1504. PMID 38657245.

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Acta Commentary:

Acta Paediatrica - 2024 - Dear - EBNEO commentary Nutritional support for moderate%E2%80%90to%E2%80%90late%E2%80%90preterm infants A randomized.pdf

This trial, Nutritional Support for Moderate-to-Late Preterm Infants – A Randomized Trial [1], aimed to assess routine nutritional interventions in moderate-to-late preterm gestation infants, as there is limited literature guiding current nutritional strategies for this population. It examines three interventions (intravenous amino acid solution versus dextrose solution until full enteral feedings were established, milk supplement when mother’s milk was insufficient versus exclusive use of mother’s milk, and taste and smell exposure before gastric tube feeding versus no exposures) and assessed body-fat percentage at 4 months corrected gestational age and time to full enteral feeding. The study found no significant differences in these outcomes.

It is well established that nutrition is essential to growth rate, body composition, and neurodevelopment. Historically, preterm infants have faltering growth after delivery and are unable to match their in-utero growth rates, and undernutrition is a primary driver [2]. Interventions that may improve growth include parenteral nutrition, early enteral feeding initiation, and introduction of smell and taste with gavage feeds. There is debate about whether the addition of short-term parenteral nutrition is beneficial to newborns, as evidence in older populations suggests there may be increased morbidities with early introduction of parenteral nutrition [3]. This publication by Alexander et al. suggests that enriched nutritional support is not beneficial to an infant’s short-term growth. Further follow-up is ongoing, with planned assessment of neurodevelopment and growth at 2 years of age [4].

This study adds to the growing literature on the addition of smell and taste during tube feedings, demonstrating that while there appear to be minimal adverse effects, there is little identified benefit. A randomized control trial published in 2021 assessed effects of smell and taste during tube feeding on the growth of infants born under 29 weeks gestation and found no difference in weight at the time of discharge [5]. A recent Cochrane review also found that exposure to smell and taste of milk has little effect on time to full sucking feeds [6], consistent with findings in this study.

Limitations of this study include applicability only to parents intending to breastfeed, lack of stratification for small for gestation infants, unblinded study design, and high rates of protocol deviation for infants in the exclusively mother’s milk intervention. Infants born at this gestational age often receive milk fortification; however, the authors did not explicitly describe the protocol for fortification. Findings cannot be applied to infants with complicated clinical courses, as most infants reached full enteral feeds by one week of life.

The authors conclude that routine nutritional interventions while transitioning to full nutrition of mothers’ milk do not affect time to full enteral feeds or body composition at 4 months corrected age. Thus providers can collaborate with caregivers to develop a feeding plan that will best support establishment of exclusive breast milk feeds. While follow-up is still ongoing, these findings have implications for nutritional options while in the NICU, reinforce the importance of lactation support, and have the potential to reduce healthcare costs and interventions during an infant’s hospital stay.

 

References

1. Alexander T, Asadi S, Meyer M, Harding JE, Jiang Y, Alsweiler JM, et al. Nutritional Support for Moderate-to-Late–Preterm Infants — A Randomized Trial. N Engl J Med. 2024;390: 1493–1504.
2. Hay WW Jr. Nutritional Support Strategies for the Preterm Infant in the Neonatal Intensive Care Unit. Pediatr Gastroenterol Hepatol Nutr. 2018;21: 234–247.
3. Fivez T, Kerklaan D, Mesotten D, Verbruggen S, Wouters PJ, Vanhorebeek I, et al. Early versus late parenteral nutrition in critically ill children. N Engl J Med. 2016;374: 1111–1122.
4. Bloomfield FH, Harding JE, Meyer MP, Alsweiler JM, Jiang Y, Wall CR, et al. The DIAMOND trial – DIfferent Approaches to MOderate & late preterm Nutrition: Determinants of feed tolerance, body composition and development: protocol of a randomised trial. BMC Pediatr. 2018;18: 220.
5. Beker F, Liley HG, Hughes IP, Jacobs SE, Macey J, Twitchell E, et al. Effects on growth of smell and taste of milk during tube feeding of preterm infants: A randomized clinical trial: A randomized clinical trial. JAMA Pediatr. 2021;175: 1115–1123.
6. Delgado Paramo L, Bronnert A, Lin L, Bloomfield FH, Muelbert M, Harding JE. Exposure to the smell and taste of milk to accelerate feeding in preterm infants. Cochrane Database Syst Rev. 2024;5: CD013038.