Neonatal nutrition plays a central role in shaping both immediate clinical outcomes and long-term health trajectories of preterm and critically ill infants. Early nutritional exposures influence organ development, immune maturation, and metabolic programming. Among nutritional interventions, human milk feeding demonstrates protective effects across multiple neonatal morbidities, including necrotizing enterocolitis (NEC), bronchopulmonary dysplasia (BPD), and impaired neurodevelopment. The bioactive components of human milk contribute to modulation of inflammation, enhancement of gut integrity, shaping the microbiota, and support of organ maturation.

Introduction Patients sometimes stay a considerable length of time within Emergency Departments (EDs) and often leave with an incomplete understanding of their health problems and treatment. The complexity of how patients and their families make sense of emergency care and what they do throughout their journey is incompletely described, typically relying on retrospective interviews. This study describes the development of a typology of their thinking and doing, and how it can be used to explain reported outcomes and potentially make the patient's journey easier.Method This paper draws on the concept of patient work to explain how patient diagnostic and treatment journeys relate to the work of staff and their endurance of that journey. Observations and informal interviews with 51 adult patients and 8 family members were undertaken in an English ED. We construct a typology to develop the concept of patient and family work during their ED journey, and how this is shaped by a healthcare context (e.g., limited patient-staff relationships and overcrowding) that is very different from chronic illness contexts that previously applied the concept.Results Findings demonstrate how patients' sensemaking work is shaped by their expectations and informational exchanges with the clinician, but gaps in sensemaking exist. Sensemaking interacts with endurance work, that is, long waits in a noisy, public environment. Families participate in and often ameliorate patient sensemaking by seeking clarification, providing information, meeting patients' commitments and easing endurance work.Conclusion Collective analysis of patients' sensemaking and endurance work demonstrates how their diagnostic and treatment journeys shape patient experiences and navigation of ED healthcare encounters, with the potential to inform interventions to ease this work.Patient and Staff Contribution This study was informed by prior co-design and observation work with patients and staff during the development of a checklist to help meet patient information needs. This highlighted the centrality of the patient-staff interaction and the need to better understand it by directly observing the patient journey.

Growth failure in infants born preterm is a significant issue, increasing the risk of poorer neurodevelopmental outcomes and metabolic syndrome later in life. The aim of this study was to characterize patterns associated with urinary metabolites in extremely preterm and very preterm infants and to explore relationships with growth over time. Untargeted hydrogen-1 nuclear magnetic resonance (1H NMR) spectroscopy was used to characterize changes in urinary metabolites over time and explore relationships with growth and nutritional intake. Partial least-squares regression models were constructed to identify metabolic variation associated with age, growth, and nutrition. Biochemical aging differed between very (mean 29.4 weeks ± 1.08 gestational age; n = 21) and extremely (≤28 weeks gestational age; n = 33) preterm infants, but these differences were not apparent when urinary metabolites were aligned to postmenstrual age. Citrate was the only metabolite significantly positively associated with weight-for-age Z-score. At weeks 1 and 2, citrate was positively associated with gestational age and a greater increase in WAZ from birth to discharge. Biochemical aging aligned to chronological age differed between very and extremely preterm infants, but this variation was lost when aligned to postmenstrual age. Urinary citrate excretion in the first two weeks of life was associated with weight gain and may be a future modifiable biomarker to improve growth outcomes.

BACKGROUND & AIMS:Congenital Heart Disease (CHD) is the most common congenital abnormality, affecting 9 per 1000 live births. Advances in surgical techniques have significantly improved survival rates but growth failure is associated with increased risk of mortality post-cardiac surgery. Improving growth amongst infants with CHD whilst awaiting surgery is an important component to reducing morbidity as well as improving longer term metabolic outcomes. A consensus-based nutrition pathway was developed and implemented into a regional paediatric cardiology service in 2017. The aim of this study was to evaluate the impact of the pathway in a larger cohort of infants with CHD in two epochs: pre-nutrition pathway implementation (Jan 2013-Dec 2016) and post-nutrition pathway implementation (Jan 2017-June 2023). METHODS:Growth measures were extracted from electronic patient records and z-scores were calculated. SuperImposition by Translation And Rotation (SITAR) models were constructed to develop a single fitted curve of growth velocity for each of the two epochs. RESULTS:Infants with CHD in the post-implementation group achieved significantly better growth outcomes in the first 4-months of life. In addition, after adjustment for group differences, weight gain velocity was significantly higher in the post-implementation epoch (p = 0.01). There was no detectable change in the prevalence of overweight or obese children at older timepoints, suggesting that the intervention did not promote the development of obesity although further analysis will be required as the cohort gets older. CONCLUSION:A nutrition pathway developed to support growth in infants with CHD before surgery was associated with better growth outcomes during the first year of life compared to an epoch when nutrition support was only given for malnourishment. Achieving normal growth patterns during the first year of life may help to reduce the risk of metabolic disease in later life, although further research will be required to elucidate this.

Background & Aims Early growth of very preterm infants is associated with later neurodevelopmental outcome. Current growth charts are based on in utero growth rather than a growth pattern associated with good outcomes. This study aimed to generate growth standards using infants who were developing normally. Methods Data were obtained from the National Neonatal Research Database. Logistic regression identified associations of in-hospital and post-discharge weight gain and head circumference growth with the chance of healthy development at two years. The LMS method was used to construct centile curves reflecting the growth of very preterm infants with a positive developmental outcome. Infants with surgical necrotising enterocolitis or a significant brain injury were excluded from the cohort used to generate growth charts. Results Growth data were available for 37700 infants, of whom 14120 had a documented developmental assessment. Healthy development was positively associated with three factors: In-hospital weight gain (adjusted OR 1·09 per unit z-score change, 95% CI: 1·02-1·17), weight gain from discharge to two-year assessment (aOR 1·08, 1·04-1·12) and in-hospital head growth (aOR 1·12, 1.04-1·21). A web app is available (www.bit.ly/preterm-plotter) to generate individualised growth charts for preterm infants, conditioned on their weight and head circumference at birth, to plot their growth and indicate whether their growth was expected to align with that of healthily developing infants. Conclusion This study presents a novel method of forming individualised growth charts. It can be implemented using a web app or by integration with clinical information systems to allow an infant’s growth to be compared to a cohort of infants with a favourable developmental outcome.

BACKGROUND:Preterm infants typically receive intravenous fluids or parenteral nutrition while milk feeds are gradually increased. Feeding with milk sooner could reduce length of hospital stay and risk of invasive infections but might increase the risk of necrotising enterocolitis. We aimed to investigate if exclusively enteral fluids (ie, full milk feeds) from day 1 compared with gradual feeding supplemented with intravenous fluids or parenteral nutrition reduces the length of hospital stay in infants born at 30 weeks and 0 days (30+0weeks) to 32+6 weeks of gestation. METHODS:This open-label, parallel-group, multicentre, randomised, superiority trial recruited mothers of infants born at 30+0 weeks to 32+6 weeks of gestation, in 46 neonatal units in UK hospitals. Infants younger than 3 h were included if they were clinically stable; those with congenital anomalies that make enteral feeding unsafe and who were small for gestational age with reversed end-diastolic flow on umbilical doppler were excluded. Parents and the clinical team could not be masked, but investigators and data analysts were masked until after database lock. The mother was randomly assigned to either full milk feeds (60-80 mL/kg per day) or gradual milk feeding (maximum of 30 mL/kg per day on day 1) with intravenous fluids or parenteral nutrition for their infant within 3 h of birth using a web-based minimisation algorithm with a random element to ensure balance on important prognostic factors. The primary outcome was length of hospital stay; events of hypoglycaemia and necrotising enterocolitis were safety outcomes and analysis was performed by intention-to-treat. This trial was prospectively registered (ISRCTN89654042) and follow-up to 24 months is ongoing. FINDINGS:Between Oct 15, 2019, and July 14, 2024, we recruited and randomly assigned 1761 mothers, enrolling 2088 infants (1047 full milk feeds, 1041 gradual feeding). Mean gestational age was 31·7 weeks (SD 0·8), which was the same in both groups, and mean birthweight was 1626·0 g (301·8) in the full milk feeds group and 1617·1 (295·2) in the gradual feeding group. Of 1047 infants in the full milk group, 494 (47·2%) were female and 552 (52·7%) were male and in 1041 infants in the gradual feeding group, 500 (48·0%) were female and 540 (51·9%) were male. Primary outcome data were missing for 18 infants in each group. We found no difference in the length of hospital stay (32·4 days [SD 13·3] in the full milk group vs 32·1 days [13·5] in the gradual feeding group; adjusted difference between means -0·02 days [95% CI -1·07 to 1·03]; p=0·97). Survival to discharge (1030 [99·6%] of 1034 vs 1027 [99·6%] of 1031; -0·004 [95% CI -0·54 to 0·53]), presence of necrotising enterocolitis (4 [0·4%] of 1030 vs 6 [0·6%] of 1027; -0·19 [-0·80 to 0·41]), and mean number of blood glucose tests <2·2 mmol/L (0·6 [SD 1·0] vs 0·5 [0·7]) were similar. Serious adverse events were similar in both groups (eight [0·8%] of 1047 infants in the full milk group vs ten [1·0%] of 1041 infants in the gradual feeding group), all were unrelated to trial intervention. INTERPRETATION:In infants born at 30+0 weeks to 32+6 weeks of gestation, full milk feeds from day 1 does not alter length of hospital stay. It does not increase the risk of necrotising enterocolitis or hypoglycaemia. FUNDING:UK National Institute of Health and Care Research.

BACKGROUND:The optimal enteral protein intake for adequate growth in preterm infants remains unclear. This systematic review evaluates the impact of protein intake from fortified human milk on growth in very preterm infants. METHODS:Randomized clinical trials from January 2005 to August 2024 were included. Eligible studies measured true enteral protein intake in preterm infants. Searches were conducted in PubMed, Embase, and Cochrane CENTRAL. Risk of bias was evaluated using the revised Cochrane Risk of Bias Tool. RESULTS:Ten randomized clinical trials (n = 646) were included. Meta-regression revealed a significant linear relationship between protein intake and weight gain (5.73 g/kg/day weight gain for each gram of protein/kg/day, p = 0.001), but not with head circumference or length gain. After adjustment for energy intake, significant relationships were found between protein intake and both weight gain and length growth. In contrast, the forest plot meta-analysis comparing high versus low protein intake showed no significant differences in weight or head circumference gain. However, infants receiving higher protein intake had greater weight at discharge (SMD 0.35, 95% CI 0.12 to 0.57, n = 312, 4 studies, high certainty) and more length growth (SMD 0.5, 95% CI 0.08 to 0.92, n = 174, 3 studies, moderate certainty). DISCUSSION AND CONCLUSION:Moderate to high-certainty evidence suggests that increased enteral protein intake improves growth outcomes in very preterm infants. REGISTRATION:PROSPERO CRD42022287991. IMPACT:This systematic review is the first to evaluate the impact of enteral protein intake on growth in preterm infants <32 weeks, using studies that measured actual intake. A positive correlation was found between protein intake and weight gain. Meta-regression suggests most premature infants may require 4.0-4.5 g/kg/day to achieve in utero growth rates, rather than 3.5-4.0 g/kg/day. The meta-analysis indicates a positive relationship between protein intake, growth in length, and discharge weight. These findings underscore the critical role of adequate protein intake in growth outcomes and highlight the need to maintain appropriate energy: protein ratios.

INTRODUCTION:Poor weight gain in infants with single ventricle cardiac physiology between stage 1 and stage 2 palliative surgeries is associated with worse outcomes. The growth of infants with single ventricle physiology, enrolled in home monitoring programmes in the United Kingdom, has not been widely described. AIM:To explore the growth of infants with single ventricle physiology supported by a home monitoring programme, at a tertiary centre in the South of England. METHODS:A retrospective review of two cohorts, comparing weight gain amongst infants with single ventricle physiology, before and following the implementation of a home monitoring programme. Inclusion was dependent on a diagnosis compatible with single ventricle physiology during the interstage. RESULTS:Enrolment into a home monitoring programme (cohort 2) was associated with 55% more infants being discharged home during the interstage period (p < 0.05). Interstage mortality did not differ between cohorts. There were no differences in interstage growth velocity between cohorts (cohort 1 23.98 ± 11.7 g/day and cohort 2 23.82 ± 8.3 g/day); however, infants in cohort 2 experienced less growth deceleration early in life, and achieved catch-up growth at 12-23 months. Interstage nasogastric feeding, regardless of the cohort, was associated with worse growth outcomes. CONCLUSION:A home monitoring programme for infants with single ventricle physiology provides the opportunity for infants to be safely discharged home to their families and cared for at home during the interstage. Infants in the home monitoring programme experienced better growth, achieving weight restoration at 12-23 months.

Nutritional management of preterm infants recovering from necrotizing enterocolitis (NEC) or focal intestinal perforation (FIP) is challenging, especially in infants managed surgically. The logistics of how, when, and what to feed are unclear and current nutritional practices are primarily based on physiological principles and consensus opinion in individual units, rather than high-quality evidence. The aim of this narrative review is to summarize the literature on nutritional management after NEC or FIP in preterm infants: when to restart enteral nutrition, type of enteral nutrition to use, and how to advance nutrition. We also discuss treatment of micronutrient deficiencies, cholestasis, replacement of stoma losses, and optimal time of stoma closure. In conclusion, there are in sufficient high-quality studies available to provide evidence-based recommendations on the best nutritional practice after NEC or FIP in preterm infants. A local or national consensus based early nutrition guideline agreed upon by a multidisciplinary team including pediatric surgeons, pediatricians/neonatologists, nurses, and nutritionists is recommended. Further studies are urgently needed.ImpactThere is no good quality evidence or nutritional standard across neonatal units treating infants after medical or surgical NEC or FIP.With this review we hope to start providing some consistency across patients and between providers treating patients with NEC and FIP.Mother's own milk is recommended when restarting enteral nutrition after NEC or FIP.In the absence of high-quality evidence, a consensus based early nutrition guideline agreed upon by a multidisciplinary team is recommended.Nutritional research projects are urgently needed in NEC and FIP patients.

Objective To determine the impact of transanastomotic tube (TAT) feeding in congenital duodenal obstruction (CDO). Design Systematic review with meta-analysis. Patients Infants with CDO requiring surgical repair. Interventions TAT feeding following CDO repair versus no TAT feeding. Main outcome measures The main outcome was time to full enteral feeds. Additional outcomes included use of parenteral nutrition (PN), cost and complications from either TAT or central venous catheter. Meta-analyses were undertaken using random-effects models (mean difference (MD) and risk difference (RD)), and risk of bias was assessed using the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool. Results Twelve out of 373 articles screened met the inclusion criteria. All studies were observational and two were prospective. Nine studies, containing 469 infants, were available for meta-analysis; however, four were excluded due to serious or critical risk of bias. TAT feeding was associated with reduced time to full enteral feeds (−3.34; 95% CI −4.48 to −2.20 days), reduced duration of PN (−6.32; 95% CI −7.93 to −4.71 days) and reduction in nutrition cost of £867.36 (95% CI £304.72 to £1430.00). Other outcomes were similar between those with and without a TAT including inpatient length of stay (MD −0.97 (−5.03 to 3.09) days), mortality (RD −0.01 (−0.04 to 0.01)) and requirement for repeat surgery (RD 0.01 (−0.03 to 0.05)). Conclusion TAT feeding following CDO repair appears beneficial, without increased risk of adverse events; however, certainty of available evidence is low. Earlier enteral feeding and reduced PN use are known to decrease central venous catheter-associated risks while significantly reducing cost of care. PROSPERO registration number CRD42022328381.

Background Care bundles may reduce neonatal CLABSIs by 60% though it is often unclear if it is the intervention, the implementation, or both, that results in CLABSI reductions. This study aimed to investigate the implementation of a CLABSI care bundle in a UK neonatal intensive care unit (NICU). Methods A focused ethnographic design was used underpinned by Normalisation Process Theory. Data collection included Normalisation MeAsure Development (NoMAD) surveys, observations of practice with dyadic think aloud interviews, and semi-structured interviews. Outcome and processes measures were collected. Data analysis used descriptive statistics and thematic analysis. Results There was only partial bundle implementation, with minimal changes in survey scores and influences across individual, team and organisational levels moderating bundle adoption. Organisational culture sometimes undermined implementation and there were challenges relating to reinforcement and endorsement. Conclusions The introduction of a care bundle into a tertiary UK NICU did not result in sustained reductions in CLABSIs, which is one of few negative studies. Understanding the mechanisms by which an intervention works (or not) in specific contexts is important to optimise the delivery of evidence-based care.

Purpose of review In recent years, there has been a burgeoning interest in using machine learning methods. This has been accompanied by an expansion in the availability and ease of use of machine learning tools and an increase in the number of large, complex datasets which are suited to machine learning approaches. This review summarizes recent work in the field and sets expectations for its impact in the future. Recent findings Much work has focused on establishing good practices and ethical frameworks to guide the use of machine learning in research. Machine learning has an established role in identifying features in ‘omics’ research and is emerging as a tool to generate predictive models to identify people at risk of disease and patients at risk of complications. They have been used to identify risks for malnutrition and obesity. Machine learning techniques have also been used to develop smartphone apps to track behaviour and provide healthcare advice. Summary Machine learning techniques are reaching maturity and their impact on observational data analysis and behaviour change will come to fruition in the next 5 years. A set of standards and best practices are emerging and should be implemented by researchers and publishers.

ObjectiveTo determine the effect of parental socioeconomic status (SES) on the postnatal growth of preterm infants.MethodsA systematic review (PROSPERO registration CRD42020225714) of original articles from Medline, Embase, CINAHL Plus and Web of Science published 1946-2023 was undertaken. Studies were included if they reported anthropometric growth outcomes for preterm infants according to parental SES. Data extraction and assessments of bias and health equity impact were conducted using custom-designed forms.ResultsA narrative synthesis of twelve included studies was performed. Most infants were moderate to late preterm. The settings, growth outcomes, timings of growth measurement, and SES measures were heterogenous. Six studies demonstrated an adverse effect of low parental SES on the extrauterine growth of preterm infants, five studies showed no effect, and one study showed a potentially beneficial effect. All studies had a high risk of bias, especially confounding and selection bias. The health equity impact of included studies was largely negative.ConclusionLimited and low-quality evidence suggests that socioeconomic minoritisation may adversely impact the growth of preterm infants, thereby widening existing socioeconomic health inequities. Observational studies informed by theorisation of the mechanistic pathways linking socioeconomic minoritisation to adverse postnatal growth are required to identify targets for intervention.ImpactLimited evidence suggests low parental socioeconomic status (SES) adversely affects the postnatal growth of preterm infants across different settings.Early growth of preterm infants predicts neurodevelopmental outcomes and the risk of cardiovascular and metabolic disease in adulthood.Systematic screening of over 15,000 articles identified only twelve studies which reported postnatal growth outcomes for preterm infants according to parental SES.The health equity impact of the included studies was systematically assessed, and found to be negative overall.This study highlights limitations in existing evidence on the association between parental SES and postnatal growth, and delineates avenues for future research.

Background: Growth failure in infants born with CHD is a persistent problem, even in those provided with adequate nutrition. Objective: To summarise the published data describing the change in urinary metabolites during metabolic maturation in infants with CHD and identify pathways amenable to therapeutic intervention Design: Scoping review. Eligibility criteria: Studies using qualitative or quantitative methods to describe urinary metabolites pre- and post-cardiac surgery and the relationship with growth in infants with CHD. Sources of evidence: NICE Healthcare Databases website was used as a tool for multiple searches. Results: 347 records were identified, of which 37 were duplicates. Following the removal of duplicate records, 310 record abstracts and titles were screened for inclusion. The full texts of eight articles were reviewed for eligibility, of which only two related to infants with CHD. The studies included in the scoping review described urinary metabolites in 42 infants. A content analysis identified two overarching themes of metabolic variation predictive of neurodevelopmental abnormalities associated with anaerobic metabolism and metabolic signature associated with the impact on gut microbiota, inflammation, energy, and lipid digestion. Conclusion: The results of this scoping review suggest that there are considerable gaps in our knowledge relating to metabolic maturation of infants with CHD, especially with respect to growth. Surgery is a key early life feature for CHD infants and has an impact on the developing biochemical phenotype with implications for metabolic pathways involved in immunomodulation, energy, gut microbial, and lipid metabolism. These early life fingerprints may predict those individuals at risk for neurodevelopmental abnormalities.

Good communication is central to good healthcare. As a result of poor communication between parents and healthcare professionals (HCPs) in clinical settings, this study aimed to address this problem by developing a communication tool to empower parents and act as a prompt for HCPs to talk about the child's care and gather information at the point of admission to hospital about what is important to families, therefore supporting patient-centered communication. A design thinking process was used to develop a physical copy of Chloe's card and evaluate its use. Design thinking is a problem-solving approach, which uses an empathetic lens to integrate viewpoints of different stakeholders throughout the process of creating solutions. Design thinking involves five processes: (1) empathise-including a literature review and data synthesis, (2) define-by completing semi-structured interviews with parents about their experience of communication and HCPs perceptions of parent's experience of communication, (3) ideate-iterate the design of Chloe's card with parents and HCPs, (4) prototype-develop the design of Chloe's card, and (5) test-pilot test in clinical practice. Results from this initial study suggest that a small hand-held card, with emoticons and a place to write concerns, was acceptable to parents and feasible to use in clinical practice. Parents do not always feel heard by HCPs and a tool such as Chloe's card may help facilitate sharing of information about matters important to them and their child. However, some HCPs felt the need for a communication tool undermined their clinical skills. Feedback from HCP participants suggests that the idea of Chloe's card was acceptable and perceived as potentially being useful in clinical practice. Further work is required, as part of a larger study, to further refine this communication tool, identify those parents who would benefit most from Chloe's card, as well as to further refine the HCP process prior to implementing it into clinical settings. It was noted future iterations would benefit from a digital version linked with a child's electronic record, as well as multi-language versions and information for parents.

Perinatal trials sometimes require rapid recruitment processes to facilitate inclusion of participants when interventions are time-critical. A two-stage consent pathway has been used in some trials and is supported by national guidance. This pathway includes seeking oral assent for participation during the time-critical period followed by informed written consent later. This approach is being used in the fluids exclusively enteral from day one (FEED1) trial where participants need to be randomised within 3 hours of birth. There is some apprehension about approaching parents for participation via the oral assent pathway. The main reasons for this are consistent with previous research: lack of a written record, lack of standardised information and unfamiliarity with the process. Here, we describe how the pathway has been implemented in the FEED1 trial and the steps the trial team have taken to support sites. We provide recommendations for future trials to consider if they are considering implementing a similar pathway. Trial registration number:ISRCTN89654042.

Background This study aimed to determine patterns of nocturnal pulse oximetry indices in moderate to late preterm infants, and investigate the relationship between oxygen desaturations, the apnoea hypopnoea index, and both corrected gestational and postnatal age. Methods 21 healthy infants born at 32 + 0 - 36 + 6 weeks gestation underwent serial nocturnal pulse oximetry studies and respiratory polygraphy studies until 40 weeks corrected gestational age (CGA). The main outcome measures were number of >3% oxygen desaturations/hour (ODI3), mean oxygen saturations, and number of apnoeas and hypopnoeas/hour. Results Median ODI3 increased between weeks 1 and 3 from 49.9 to 85.4/hour ( p = 0.017). Mean oxygen saturations reached a corresponding nadir of 96.0% in week 3, then increased to 96.8% in week 6 ( p = 0.019). Mixed effects modelling demonstrated that ODI3 and mean saturations were influenced by postnatal age but not CGA ( p < 0.05). Desaturations frequently occurred without an apnoea or hypopnoea. Conclusion ODI3 rises then falls during the first 8 weeks of life in moderate to late preterm infants, independently of CGA. These interesting preliminary results highlight the importance of further serial data collection to generate age-specific normal ranges, and develop a better understanding of respiratory control in preterm infants. Impact The frequency of > 3% oxygen desaturations (ODI3) in healthy moderate to late preterm infants rises then falls after birth, peaking in postnatal week 3. There is a corresponding nadir in mean saturations. There were significant non-linear relationships between ODI3/mean saturations and postnatal age, but not corrected gestational age. The majority of brief oxygen desaturations occurred without an apnoea or hypopnoea. Normal ranges for oxygen saturation indices are not known in this population. These results demonstrate the need for further serial data collection to generate age-specific normal ranges and inform oxygen prescribing guidelines.

The pandemic arising from the severe acute respiratory syndrome coronavirus 2 (SARSCoV2) known as COVID19 has had wide reaching primary and secondary health implications.1 At the end of March 2020, in order to slow the rate of infection, the United Kingdom (UK) government implemented a strict lockdown including; the closure of schools, workplaces and restrictions on outdoor movements other than for exercise or essential shopping, which lasted until early June 2020. During this period, the National Health Service (NHS) experienced cessation of many services, whilst others imposed changes to reduce visitors and footfall on hospital sites. This included stringent and restrictive measures as to how women gave birth in addition to how Neonatal Services operated. In April 2020, the British Society of Perinatal Medicine published extensive guidance on reducing the transmission and spread of COVID19 amongst families and their newborns.2 As a result, all nonessential maternity care stopped, with inperson appointments changed to telephone or video consultations. Strict social distancing measures were implemented by units around the country by limiting partners of women to attend births (with many women giving birth alone except from the care of healthcare professionals), as well as reducing parental access to infants, particularly those born preterm or unwell, with only one parent at a time allowed by the cot side and no additional visits from the immediate or extended family. The aim of this study was to explore the experiences, information and support needs and decision making of parents with a preterm or unwell neonate during the COVID19 pandemic. An online survey was developed as part of a larger study investigating the experiences of children and young adults with serious health conditions and their parents.3 The survey opened after the end of the first UK national lockdown (01/07/202001/09/2020) a URL link to the survey was distributed, using snowball sampling, through the national charity, Baby Life Support System (Bliss) and the Neonatal Unit, Princess Anne Hospital, Southampton via through their social media. The survey was also open to all parents who were able to access it via a URL link. The study was approved by the University of Southampton and NHS Health Research Authority Research Ethics Committees (Ethics Number IRAS nr. 282176). The survey contained four sections with an open text box on Experiences, Information, Decision Making and Support needs. Each section started with a free text box for comments, with simple introductory questions: Experiences ‘Can you tell us about your experiences and views on the virus in relation to your baby/babies?’; Information: ‘Can you tell us where you get information on the virus and what other information you might need?’; Decisions: ‘Can you tell us how you make decisions about looking after your baby/babies in relation to the virus?’, Support: ‘What additional support would you like, at home or in hospital, in relation to the virus?’. One hundred and seven participants completed the survey. 103 (96%) were mothers and four (4%) were fathers. The median (IQR) parental age was 29.5 years (28– 34) with 50% of preterm infants born before 33 weeks gestation. Thematic content analysis was conducted on the free text data and was informed by a threestage coding process.4 In stage 1, an initial sample of 226 comments was open coded into broad comment categories by two researchers (NC and LM) and used to develop a framework. Disagreements over coding placement were resolved by a third researcher (ASD). For stage 2, this bestfit framework was used to refine the dataset further and finally, during stage 3, overarching themes were developed. As there was considerable overlap in the rich data within the sections, the total number of comments did not match the number of participants. A total of 226 comments were coded. Experiences (n = 58 comments), Information (n = 58 comments), Decisions (n = 48 comments), Support (n = 39 comments), Other (n = 23 comments). Thematic content analysis identified three overarching themes: (1) Virus: with a subtheme of risk of infection; (2) Impact of restrictions: with a subtheme of (i) loneliness, (ii) missed experiences and (iii) psychological impact on maternal bonding, (3) Information and support needs: with a subtheme of (i) information on preterm infants vulnerability and (ii) mental health and wellbeing (Table S1 summarises these themes and subthemes, together with illustrative comments for each one). Many parents felt there was a significant psychological and emotional impact due to COVID19 restrictions on the birthing experience and afterwards and on their neonatal intensive care journey. Findings from the SHARE studies exploring the views of parents of children with cancer, and parents of children with congenital heart disease found that parents were worried about the virus in the context of their child's disease condition.3 This is a similar finding to parents views in the preterm population. However, parents within the preterm survey reported additional concerns about their face being covered by a mask, and the subsequent ability to bond with their baby. Parents were also concerned about their baby being unable

Infants born before 32 weeks’ postmenstrual age are at a high risk of growth failure. International guidelines have long recommended that they match the growth of an equivalent fetus, despite the challenges posed by ex utero life and comorbidities of prematurity. Several groups have recently questioned the necessity or desirability of this target, shifting attention to aiming for growth which optimises important long-term outcomes. Specifically, recent research has identified the neurodevelopmental benefits of enhanced growth during the neonatal period, but work in term infant suggests that rapid growth may promote the metabolic syndrome in later life. In this context, defining a pattern of growth which optimises outcomes is complex, controversial and contested. Even if an optimal pattern of growth can be defined, determining the nutritional requirements to achieve such growth is not straightforward, and investigations into the nutritional needs of the very preterm infant continue. Furthermore, each infant has individual nutritional needs and may encounter a number of barriers to achieving good nutrition. This article offers a narrative review of recent evidence for the competing definitions of optimal growth in this cohort. It examines recent advances in the determination of macronutrient and micronutrient intake targets along with common barriers to achieving good nutrition and growth. Finally, key implications for clinical practice are set out and a recommendation for structured multidisciplinary management of nutrition and growth is illustrated.