We undertook this review to determine if it is plausible that choline or phosphatidylcholine (PC) deficiency is a factor in necrotizing enterocolitis (NEC) after two clinical trials found a dramatic and unexpected reduction in NEC in an experimental group provided higher PC compared to a control group. Sources and amounts of choline/PC for preterm infants are compared to the choline status of preterm infants at birth and following conventional nutritional management. The roles of choline/PC in intestinal structure, mucus, mesenteric blood flow, and the cholinergic anti-inflammatory system are summarized. Low choline/PC status is linked to prematurity/immaturity, parenteral and enteral feeding, microbial dysbiosis and hypoxia/ischemia, factors long associated with the risk of developing NEC. We conclude that low choline status exists in preterm infants provided conventional parenteral and enteral nutritional management, and that it is plausible low choline/PC status adversely affects intestinal function to set up the vicious cycle of inflammation, loss of intestinal barrier function and worsening tissue hypoxia that occurs with NEC. In conclusion, this review supports the need for randomized clinical trials to test the hypothesis that additional choline or PC provided parenterally or enterally can reduce the incidence of NEC in preterm infants.Impact statementLow choline status in preterm infants who are managed by conventional nutrition is plausibly linked to the risk of developing necrotizing enterocolitis. [GRAPHICS] .

Background: Postnatal growth failure is common in very preterm infants and is associated with worse neurodevelopmental outcome. Objective: To evaluate the cumulative impact of multiple evidence based strategies on the postnatal growth of extremely-low-birth-weight (ELBW) infants. Methods: We conducted a prospective observational study. Based on current literature, changes were implemented to provide optimal parenteral and enteral nutrition. Daily intakes of calories, protein, lipids and carbohydrates were calculated. The average growth velocity (GV) was calculated using 2-point exponential model and is reported as grams/kg/day. The length and head circumference gains are reported as centimeters/week. Results: The mean gestational age and birth weight for 38 ELBW survivors were 27.0 +/- 2.1 weeks and 752 +/- 147 g respectively. The GV was 13.2 +/- 2.2 g/kg/day (range 8.8-17.4) and gains in length and head circumference were 0.88 +/- 0.9 (range 0.15-1.42) and 0.71 +/- 0.5 (range 0.22-0.96) centimeters/week respectively. Twenty nine (76.3%) infants were small-for-gestational-age (SGA) at discharge and 23 of these (60.5% of all infants) had weight below 3rd percentile. All 11 infants who were SGA at birth were SGA at discharge as well. Of 25 appropriate-for-gestational-age (AGA) infants at birth, 16 (64%) were SGA at discharge. The number of infants with length and head circumference below 10th percentile at birth and discharge were 11 (28.9%) and 29 (76.3%) for length and 20 (52.6%) and 27 (71.1%) for head circumference. Infants with multiple morbidities and more hospital days with no enteral feeds had lower GV. Conclusion: All infants born SGA at birth and majority of ELBW survivors born AGA at birth had weight, length and head circumference below 10th percentile at discharge despite aggressive nutrition supplementation. (c) 2021 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

Understand the importance of having the appropriate number of dietitian FTEs assigned to the neonatal critical care unit to help improve growth parameters for preterm infants.

Working with an infant or child who has intestinal failure (IF) can be a real challenge for nutritional professionals. It truly does take a village to help care for these kids suffering from IF have an improved quality of life. Being independent of parental nutrition (PN) is the long-term goal as well as consuming a variety of foods. In recent years, clinical research has shown prescribing Omega 3-based intravenous fat emulsions IVFE) along with PN, slows down the progression and even reverses the potentially fatal complication of cholestatic jaundice. But using these types of IVFE is still only a temporary remedy. The eventual goal is to transition these children to a 100% enteral diet either with all real food, an amino acid based formula, or a combination of both.

Background. Traditionally, dietary fiber has been empirically added to infant formulas to improve feeding intolerance for those infants diagnosed with intestinal failure (IF) or short-bowel syndrome (SBS). Clinicians have added a variety of products such as pectin, Benefiber, infant cereals, or baby foods as the dietary fiber source, without documented evidence of their efficacy. Materials and Methods. This was a retrospective cohort review of infants admitted between August 2003 and June 2011 to the Children’s Hospital of Illinois who had dietary green beans added to their formula because of feeding intolerance. Our primary hypothesis was that adding dietary fiber as green beans to an infant’s formula would correct diarrhea resulting from a bowel resection and reduce their dependence on parenteral nutrition (PN). Results. In all, 18 infants were prescribed dietary green beans added to their formula during this study period; 7 of them were diagnosed with SBS. After the addition of the dietary green beans to their formula, all infants had improvements in stool consistency: 56% of the infants had mushy/soft stools, and 44% of the infants had formed stools. Also, 61% of infants had PN discontinued because 100% of their nutritional needs were met by enteral feedings. Conclusion. Infants with IF or SBS stool patterns improved after dietary green beans were added to the formula. The addition of this type of dietary fiber may allow the clinician to advance enteral feeding volumes and decrease the infant’s dependence on PN and avoid associated PN-related morbidities.

Background. Neonates who undergo surgery and have an ostomy with a creation of a mucous fistula are at nutritional risk, especially if the ostomy placement is proximal and the remaining bowel is not being used. Total parenteral nutrition (TPN) is used to maintain the neonatal nutritional status, but long-term use is associated with increased morbidities. The concept of reinfusing succus entericus into the mucous fistula to decrease the neonate’s dependence on TPN has been limited to case reports. Methods. This is a retrospective cohort study documenting the effectiveness of reinfusing succus entericus into the mucous fistula for neonates admitted to the neonatal intensive care unit (NICU). The authors’ primary hypothesis was that neonates who had succus entericus reinfused into the mucous fistula had decreased dependence on TPN. Results. Of the premature infants receiving mucous fistula feedings, 65% had TPN discontinued, whereas 67% of the term infants had TPN discontinued. The type of ostomy affected the neonate’s ability to be weaned off TPN. In all, 80% of the neonates with ileostomies were able to have TPN discontinued as compared with only 38% of the neonates with jejunostomies. Conclusions. The reinfusion of succus entericus into the mucous fistula decreases the neonate’s dependence on TPN and may prevent the progression of TPN-related morbidities from long-term use. Reinfusion of succus entericus into the mucous fistula may be a beneficial practice for neonates with ostomy placements.

Objective. The goal of this study was to determine if micropreemies could tolerate higher infusion rates of intravenous fat emulsions (IVFEs) during the first week of life by maintaining their serum triglyceride levels at <200 mg/dL. Methods. This was a randomized controlled trial of 19 infants who were classified as appropriate for gestational age and had birth weights between 500 and 750 g. The primary clinical outcome was serum triglyceride levels; secondary outcomes also were monitored. Results. A total of 19 micropreemies completed the study (experimental group: n = 10; control group: n = 9). Of the infants in the experimental group, 100% had developed hypertriglyceridemia (>201 g/dL) during the first week of life compared with only 44.4% of the infants in the control group. The experimental group experienced a lower weight loss of 8.6% ± 3.10% as compared with 16.22% ± 8.04% in the control group during the first week of life. Initially, the experimental group was given significantly higher infusion rates of IVFEs, but at the end of the week, the control group was receiving significantly higher infusion rates of IVFEs. Calorie intake was significantly better initially for the experimental group, but because of the incidences of hypertriglyceridemia and a reduction of IVFEs, the control group had significantly better calorie intake at the end of the study period. Conclusions. Micropreemies do not tolerate initial higher infusion rates of IVFEs during the first week of life because of their potential risk for developing hypertriglyceridemia.

The objective of this study was to determine if there are any common “risk factors” that could assist clinicians in identifying premature infants who are at greater risk for developing necrotizing enterocolitis (NEC). This was a retrospective study of infants admitted to the neonatal intensive care unit at Children’s Hospital of Illinois, Peoria. In total, 384 charts were reviewed. Seventy-eight infants diagnosed with NEC were compared to 246 infants who did not have NEC. Maternal risk factors, infant demo-graphics, incidence of sepsis, H2 blockers prescribed, temperature, anemia, and day-of-life gut priming and enteral feedings were compared between the two groups for significant differences. Univariate tests and logistic regression demonstrated that mothers of infants who developed NEC had a higher incidence of premature rupture of membranes. Significantly more males developed NEC than females. African American infants had a higher incidence of developing NEC than white infants. Infants who developed NEC often had a prior diagnosis of sepsis and were prescribed H2 blockers more frequently. Infants who had early initiation of gut priming and earlier initiation of enteral feedings had significantly less incidence of NEC than infants whose gut priming and enteral feedings were delayed. This study supports that risk factors for NEC are multifactorial and could assist clinicians in identifying subgroups, within the neonatal population, that are at greater risk for this disease, leading to the implementation of strategies to reduce the onset of NEC. Unfortunately, the true etiology of NEC remains unclear.

The objective of this study was to determine if there are any “risk factors” that could assist clinicians in identifying premature infants who are at greater risk for mortality when developing necrotizing enterocolitis (NEC). This was a retrospective study of infants admitted to the neonatal intensive care unit (NICU) at Children’s Hospital of Illinois, Peoria. Seventy-eight patients were diagnosed with NEC and were divided into 2 groups: NEC-survived versus NEC-died. Maternal risk factors, infant demographics, birth weight, incidence of sepsis, histamine-2 (H2) receptor blockers prescribed, temperature, anemia, and day of life when trophic feedings were begun and when enteral feedings were advanced were compared for significant differences. Univariate tests demonstrated that mothers of infants who died from NEC had a higher incidence of premature rupture of membranes. A premature infant’s decreasing birth weight significantly increased the risk for NEC-related mortality. Premature infants who received early trophic feedings had less NEC-related mortality, but this finding was not significant. Other conditions such as maternal risk factors, H2 blockers in total parenteral nutrition, enteral feedings, and temperature were not significant. Logistic regression indicated that a premature infant’s birth weight significantly increased his or her probability of dying from NEC while adjusting for other variables. A premature infant’s birth weight could be used by clinicians as a tool to identify patients at greater risk for NEC-related mortality. Although the true etiology of NEC remains unclear, early initiation of trophic feedings with colostrum may be the best defense for preventing the onset of this devastat- ing disease.

The purpose of this study was to compare the clinical outcomes of 2 different oral feeding protocols. The old protocol advanced oral feedings based on established feeding times, whereas the new evidenced-based protocol advanced oral feedings using infant cues. This retrospective study, conducted by reviewing the charts of premature infants born less than or at 34 weeks' gestation, documented the differences between the 2 oral feeding protocols. The medical records were reviewed for 200 premature infants admitted to the neonatal intensive care unit at Children's Hospital of Illinois, Peoria, Illinois. The main outcome variables this study compared were when infants started oral feedings, time to achieve 50% and 100% feedings orally, weight at time of oral feeding, day of life, and postmenstrual age. The percentage of feedings when oral stimulation was ordered, frequency of feeding therapy consultations, length of stay, weight at the time of discharge, and postmenstrual age at the time of discharge were also compared. Infants participating in the new feeding protocol began oral feedings at an earlier postmenstrual age as compared to infants using the old feeding protocol. Participants enrolled in this new protocol did not experience adverse events. They were also able to progress to full oral feedings while maintaining adequate weight, had less need for feeding therapy consultations, and length of stay was not prolonged.

OBJECTIVE. The goal was to determine whether very low birth weight infants could tolerate higher rates of infusion of intravenous fat emulsion during the first week of life and maintain their serum triglyceride levels at ≤200 mg/dL. METHODS. This was a randomized, controlled trial of 110 infants who were classified as appropriate for gestational age and had birth weights between 750 g and 1500 g. The primary clinical outcome was serum triglyceride levels; secondary outcomes also were monitored. RESULTS. One hundred infants completed the study (experimental group: N = 48; control group: N = 52). Infants in the experimental group had significantly higher energy intake for the entire 7-day study period and achieved 90 kcal/kg per day (1 kcal = 4.184 kJ) significantly sooner (7.38 ± 3.381 days vs 9.44 ± 3.578 days). Triglyceride levels for infants in the experimental group remained significantly higher for the first 5 days of life. Fifteen percent of infants in the experimental group but only 4% of infants in the control group developed hypertriglyceridemia. Ten percent of infants in the control group but no infants in the experimental group required insulin therapy. Forty-two percent of infants in the experimental group and 17% of infants in the control group remained at ≥10th percentile for weight for age. Fourteen percent of infants in the control group but no infants in the experimental group developed necrotizing enterocolitis. Twenty-three percent of infants in the control group but only 6% of infants in the experimental group developed retinopathy of prematurity. There were no significant differences in other outcomes. CONCLUSIONS. Very low birth weight infants can tolerate higher rates of infusion of intravenous fat emulsion solutions during the first week of life without significant adverse events.

Breast milk is the optimal source of nutrition for infants. According to research, neonates fed breast milk have a reduced risk of sepsis, increased feeding tolerance, a decreased incidence of necrotizing enterocolitis, and better neurodevelopmental outcomes. Unfortunately, researchers have not identified practices to reduce or eliminate the risk for errors in breast milk administration. This article discusses the potential hazards of incorrect administration of breast milk. It then describes how the tertiary care center at Children’s Hospital of Illinois implemented a policy utilizing six sigma quality improvement methodologies to improve breast milk administration. Since implementation of this policy, the NICU at our hospital has reduced the risk of breast milk administration errors to less than 3.4 mistakes per million opportunities.

Feeding intolerance is a common problem in infants who have had multiple or extensive resections of their small bowel. Chronic malabsorption and diarrhea are common side effects that inhibit the advancement of enteral feedings and prolong dependence on parenteral nutrition (PN). Poor growth, recurrent central line infections, cholestasis, and osteopenia are well-known complications associated with long-term PN dependency. It has been shown that, in adults with short bowel syndrome, providing dietary fiber can improve tolerance to enteral feeding. There are no published studies that have addressed the influence of dietary fiber on feeding intolerance in infants after bowel resections. The ensuing case studies illustrate the positive outcomes of fiber use in infants with diarrhea secondary to small bowel resections.

Background: Although the component of sucking and swallowing is present in the premature neonates at 28 weeks of gestation, the synchrony is irregular and oral feeding is difficult. The oral feedings become coordinated by 32–34 weeks of gestation and so the premature neonates are usually offered oral feeding at 32–34 weeks corrected gestational age. We had several neonates who were discharge home at ≤ 34 weeks of gestation. In order for them to be discharged at ≤ 34 weeks of gestation age, they must have had their oral feedings started earlier then 32 weeks of corrected age. Retrospective study was done to find out the earliest gestational age at which it would be safe to initiate oral feedings for early discharge from NICU. Methods: We reviewed all the charts for the neonates who were discharge home from our neonatal intensive care unit (NICU) at ≤ 34 weeks corrected gestational age from October 1, 2001 to December 31, 2002. The data was collected for gestational age, birth weight, sex, corrected gestational age, day of life the oral feedings were initiated, discharge weight and length of stay. Results: We had total 50 patients who were discharged home during the study period who were ≤ 34 weeks of corrected gestational age. Conclusion: Oral feedings can be initiated as early as 30 weeks of corrected gestational age in neonates. Early initiation of oral feedings may shorten the length of stay in NICU. Fig. 1