Objective: Preterm infants exhibit an aberrant inflammatory response, characterized by elevated intestinal and systemic inflammatory markers, and their relationship remains poorly understood in neonatal immunology. Our study aimed to examine the association and temporal relationship between intestinal and systemic inflammation. Study Design: This retrospective observational study included n = 74 infants who were born preterm (<34 weeks of gestation). Urine and blood samples were collected throughout the hospitalization period between 1-20 weeks of life. Urinary I-FABP (intestinal fatty acid binding protein) was measured as a marker of intestinal inflammation, and blood samples were analyzed for systemic inflammatory markers, including CRP, ICAM-1, IL-1β, IL-6, and IL-8. Unadjusted linear mixed-effects models were used to assess longitudinal trends and both concurrent and lagged associations between urinary I-FABP and systemic inflammatory markers. Results: Our longitudinal analyses revealed a significant decrease in levels of I-FABP (ß = -0.32, p < 0.001), IL-6 (ß = -0.03, p = 0.003), and IL-8 (ß = -0.11, p < 0.001), and a significant increase in levels of ICAM-1 (ß = 0.04, p < 0.001) over time. Within the same week, I-FABP was significantly associated with all systemic inflammatory markers except for CRP. Lagged associations between I-FABP levels measured one week before systemic biomarker assessment to determine whether intestinal inflammation temporally precedes systemic inflammation revealed significant positive associations with ICAM-1, IL-1β, and IL-8 (ß = 0.14, p = 0.008; ß = 0.15, p = 0.009; ß = 0.36, p < 0.001, respectively). Conclusion: Our exploratory study revealed significant associations between urinary I-FABP and systemic inflammatory markers, with intestinal inflammation preceding systemic inflammation. These findings suggest a potential temporal progression from intestinal to systemic inflammation, offering new insight into inflammatory dynamics and immune responses in preterm infants.

PURPOSE:To evaluate maternal dietary intake during pregnancy compared with the 2015-2020 and 2020-2025 Dietary Guidelines for Americans (DGA).STUDY DESIGN AND METHODS:A retrospective observational study design was used. The cohort included women who gave birth to preterm infants between 25 1/7 weeks and 33 6/7 weeks of gestation. Within 2 weeks of birth, participants were asked to recall their diet in the last month of pregnancy using the Dietary Screener Questionnaire. Participants' dietary intakes were compared to current 2020-2025 DGA that include specific recommendations for pregnant women and prior 2015-2020 DGA that were in place during the study period but were not pregnancy-specific.RESULTS:Forty-five women participated in the study. None met the 2015-2020 or 2020-2025 DGA recommended intake of all seven dietary components. When compared to both DGAs, 2.2% of participants met the recommended dairy intake, 26.7% met the calcium intake, 15.6% were below the threshold for added sugar, and none met the vegetable or whole grain intake. When compared to the 2015-2020 DGA, 28.9% met the fruit intake and 2.2% met the fiber intake. However, when compared to the 2020-2025 DGA, only 2.2% met the fruit intake and none met the fiber intake.CLINICAL IMPLICATION:Women who gave birth preterm did not adhere to the 2015-2020 or 2020-2025 DGA recommendations in the last month of pregnancy. Nurses are uniquely positioned to provide pregnant women with nutritional screening and counseling as part of routine prenatal care.

BACKGROUND:While a growing body of literature has established the role of human milk as a mechanism of protection in the formation of the infant gut microbiome, it remains unclear the extent to which this association exists for infants with neonatal opioid withdrawal syndrome. PURPOSE:The purpose of this scoping review was to describe the current state of the literature regarding the influence of human milk on infant gut microbiota in infants with neonatal opioid withdrawal syndrome. DATA SOURCES:CINAHL, PubMed, and Scopus databases were searched for original studies published from January 2009 through February 2022. Additionally, unpublished studies across relevant trial registries, conference proceedings, websites, and organizations were reviewed for possible inclusion. A total of 1610 articles met selection criteria through database and register searches and 20 through manual reference searches. STUDY SELECTION:Inclusion criteria were primary research studies, written in English, published between 2009 and 2022, including a sample of infants with neonatal opioid withdrawal syndrome/neonatal abstinence syndrome, and focusing on the relationship between the receipt of human milk and the infant gut microbiome. DATA EXTRACTION:Two authors independently conducted title/abstract and full-text review until there was consensus of study selection. RESULTS:No studies satisfied the inclusion criteria, which resulted in an empty review. IMPLICATIONS FOR PRACTICE AND RESEARCH:Findings from this study document the paucity of data exploring the associations between human milk, the infant gut microbiome, and subsequent neonatal opioid withdrawal syndrome. Further, these results highlight the timely importance of prioritizing this area of scientific inquiry.

AbstractObjectiveTo assess maternal dietary intake during pregnancy and adherence to the 2020–2025 pregnancy‐specific Dietary Guidelines for Americans (DGA).MethodsThis was a retrospective observational study. The study population consisted of women who gave birth to term infants (>37 weeks of gestation). Participants were given the Dietary Screener Questionnaire (DSQ) after birth and asked to recall their dietary intake in the last month of pregnancy. Participants' estimated dietary intakes were then compared to the 2020–2025 DGA which includes specific recommendations for pregnant women.ResultsOut of 51 women who completed the DSQ, none consumed the recommended amounts of all surveyed dietary factors. Specifically, only one woman (2%) met the recommended intake of fruits, 11 women (22%) met the recommended intake of calcium, 25 women (49%) exceeded the recommended upper limit for added sugar intake, and none of the women (0%) met the intake of vegetables, whole grains, dairy and fiber.ConclusionWomen in our study did not adhere to the pregnancy‐specific DGA recommendations in the last month of pregnancy. Our findings underscore the need to increase maternal nutritional awareness and education to improve adherence to the DGA.

Background: While a growing body of literature has established the role of human milk as a mechanism of protection in the formation of the infant gut microbiome, it remains unclear the extent to which this association exists for infants with neonatal opioid withdrawal syndrome. Purpose: The purpose of this scoping review was to describe the current state of the literature regarding the influence of human milk on infant gut microbiota in infants with neonatal opioid withdrawal syndrome. Data Sources: CINAHL, PubMed, and Scopus databases were searched for original studies published from January 2009 through February 2022. Additionally, unpublished studies across relevant trial registries, conference proceedings, websites, and organizations were reviewed for possible inclusion. A total of 1610 articles met selection criteria through database and register searches and 20 through manual reference searches. Study Selection: Inclusion criteria were primary research studies, written in English, published between 2009 and 2022, including a sample of infants with neonatal opioid withdrawal syndrome/neonatal abstinence syndrome, and focusing on the relationship between the receipt of human milk and the infant gut microbiome. Data Extraction: Two authors independently conducted title/abstract and full-text review until there was consensus of study selection. Results: No studies satisfied the inclusion criteria, which resulted in an empty review. Implications for Practice and Research: Findings from this study document the paucity of data exploring the associations between human milk, the infant gut microbiome, and subsequent neonatal opioid withdrawal syndrome. Further, these results highlight the timely importance of prioritizing this area of scientific inquiry.

The Department of Health and Human Services has officially acknowledged the importance of telehealth during the pandemic, issuing a notice on March 30 assuring health care providers that they would be shown leniency if telehealth services offered in good faith led to breaches of the 1996 Health Insurance Portability and Accountability Act (HIPAA). HIPAA created guidelines for the management of patients’ health information and privacy protection.

ABSTRACT Evidence suggests that the type of nutrition fed to preterm infants influences their intestinal microbiome and immunity. However, few studies have conducted a longitudinal analysis of the microbiota of mother’s own milk (MOM) and the factors shaping its composition. Furthermore, the microbiota of pasteurized donor human milk (PDHM) and infant formula have not been extensively investigated. Here, we examine the microbiota of 238 MOM, 30 PDHM, and 73 formula samples from a cohort of 72 preterm infants using 16S rRNA sequencing. We find differences in the microbial diversity and composition between nutrition types. Additionally, we demonstrate that the microbiota of MOM exhibits temporal fluctuations and has associations with several maternal factors. Lastly, we identify three microbiota community clusters within MOM—termed lactotypes—that have distinct taxonomic compositions and maternal factors. Collectively, our findings lay the foundation for exploring the relationship between the microbiota of nutrition and preterm infant health outcomes. IMPORTANCE Despite a growing recognition that the type of nutrition received by preterm infants influences their intestinal microbiome and health outcomes, the microbiota of mother's own milk (MOM), pasteurized donor human milk (PDHM), and infant formula remain poorly characterized. In our study, we found that the structure of microbial communities, bacterial diversity, and relative abundances of specific genera were significantly different between MOM, PDHM, and formula. Additionally, our results suggest that the microbiota of MOM changes as a function of time and maternal factors. Lastly, we identified three lactotypes within MOM that have distinct microbial compositions and described the maternal factors associated with them. These findings set the stage for future research aimed at advancing our knowledge of the microbiota of preterm infant nutrition and the specific influence it may have on health outcomes.

Postnatal acquisition of the microbiome is critical to infant health. In preterm infants, empiric use of antibiotics is common, with significant health consequences. To understand the influence of antibiotics on acquisition of the microbiome over time, we longitudinally profiled microbial 16S rRNA in the stool of 79 preterm infants during their hospitalization in the intensive care unit and compared antibiotic treated and untreated infants. Despite similar clinical presentation, antibiotic treated infants had strong deviations in the content, diversity, and most dramatically, temporal stability of their microbiome. Dysbiosis and fluctuations of microbiome content persisted long after antibiotic exposure, up to hospital discharge. Microbiome diversity was dominated by a few common bacteria consistent among all infants. Our findings may inform clinical practice related to antibiotic use and targeted microbial interventions aimed at overcoming the adverse influence of antibiotics on the microbiome of preterm infants at specific developmental time points.

To compare pH of human milk types (mother's own milk (MOM), pasteurized donor human milk (PDHM), fortified MOM, and fortified PDHM) fed to preterm infants.This observational study consisted of 63 mother-infant dyads < 34 weeks gestation. Human milk samples (n = 245), along with maternal factors, were collected for pH analysis. pH of MOM was analyzed over the course of lactation accounting for fortification status, postpartum day, and storage conditions.Mean pH of MOM was slightly acidic at 6.60 ± 0.28, which was significantly higher (p < 0.05) than other milk types. pH of MOM varied by fortification, postpartum day, and maternal vegetable/fiber intake. There was a significant interaction between fortification status and postpartum day; pH of MOM decreased over time, while pH of fortified MOM increased over time.pH of human milk varied by type. pH of MOM was significantly associated with fortification status, postpartum day, and maternal vegetable/fiber intake.

Preterm birth affects more than 10% of all births worldwide. Such infants are much more prone to Growth Faltering (GF), an issue that has been unsolved despite the implementation of numerous interventions aimed at optimizing preterm infant nutrition. To improve the ability for early prediction of GF risk for preterm infants we collected a comprehensive, large, and unique clinical and microbiome dataset from 3 different sites in the US and the UK. We use and extend machine learning methods for GF prediction from clinical data. We next extend graphical models to integrate time series clinical and microbiome data. A model that integrates clinical and microbiome data improves on the ability to predict GF when compared to models using clinical data only. Information on a small subset of the taxa is enough to help improve model accuracy and to predict interventions that can improve outcome. We show that a hierarchical classifier that only uses a subset of the taxa for a subset of the infants is both the most accurate and cost-effective method for GF prediction. Further analysis of the best classifiers enables the prediction of interventions that can improve outcome.

Background:Implementing innovative approaches to vascular access can be challenging in the newborn intensive care unit (NICU). Purpose:The purpose of this project was to describe the implementation of extended dwell peripheral intravenous (EPIV) catheters, a vascular access device not widely used in the NICU. The implementation involved (1) designing clinical criteria for EPIV catheter use, (2) education of vascular access NICU nurses, and (3) comparing clinical outcomes between vascular access devices (ie, PIV and EPIV catheters). Methods:We developed evidence-based clinical criteria guiding the use of vascular access devices. We then developed an educational plan for NICU nurses focused on vascular access. Finally, we collected and compared demographic characteristics and clinical data on catheter type and placement attempts, dwell time, and clinical complications associated with each catheter. Results:EPIV catheters were implemented according to evidence-based criteria by a vascular access NICU nursing team. Fifteen percent of PIV catheter placements required 3 or more attempts compared with just 1% of EPIV catheter placement attempts. EPIV catheters had a longer median dwell time (3.5 vs 1 day) and fewer complications than PIV catheters (P < .001). Implications for Practice and Research:Implementation of an evidence-based approach to vascular access by a team of NICU nurses may improve clinical outcomes. EPIV catheters may be an appropriate alternative device to PIV catheters due to fewer placement attempts, longer dwell times, and overall fewer complications during use. Future vascular access research in the NICU may include a greater focus on innovative placement strategies, optimal maintenance and infection control, and prevention of complications.

ABSTRACT Objective: The aim of the study was to assess intestinal inflammatory measures, urinary intestinal fatty acid‐binding protein (IFABP), and fecal calprotectin (FC) by gestational age (GA) and postmenstrual age (PMA) and determine the association between intestinal inflammation and growth in preterm infants from birth to hospital discharge. We hypothesized that intestinal inflammation is associated with adverse growth in preterm infants. Methods: We assayed repeated measures of IFABP and FC in 72 hospitalized preterm infants (<34 weeks’ gestation). We calculated weight and length z scores at birth and discharge using the Fenton growth reference. Associations between mean IFABP or FC, growth z scores at discharge, and growth faltering (weight or length z score difference <−0.8 from birth to discharge) were assessed using mixed linear and logistic regression models, adjusted for intrafamilial correlation and potential confounders: GA, sex, birth z score, race/ethnicity, and maternal age. Results: Mean IFABP was greater among infants born at earlier GA and decreased with increasing PMA. Mean FC did not vary by GA or PMA. Higher mean IFABP and FC were associated with lower discharge growth z scores and greater likelihood of growth faltering significant only for mean IFABP and discharge length z score (β = −0.353, 95% confidence interval [CI]: −0.704 to −0.002) and mean IFABP and length faltering (odds ratio [OR] 1.99, P = 0.018). Conclusions: Intestinal inflammation, measured by IFABP, was associated with lower length z scores and length faltering at discharge. Interventions to prevent intestinal inflammation may improve linear growth among preterm infants.

Background: Pasteurized donor human milk (PDHM) supplementation for healthy infants is an emerging practice. Little is known about demographics or breastfeeding outcomes for dyads whose mothers choose PDHM versus formula. Research Aims: To identify relationships between in-hospital supplementation choice and (1) dyad characteristics and breastfeeding intent, and (2) breastfeeding outcomes at 1 month. Materials and Methods: This exploratory prospective cohort study surveyed healthy dyads requiring medically indicated supplementation. Participants completed questionnaires including demographics, breastfeeding intent, and self-efficacy during hospitalization, and self-efficacy and lactation outcomes at 1 month. Results: Of 39 participants, 24 (62%) supplemented with formula and 15 (38%) with PDHM. Formula dyads were more likely than PDHM dyads to have a delivery body mass index (BMI) ≥30 kg/m2 (58% versus 20%, p = 0.02), and less likely to have attained greater than a college degree (33% versus 7%, p = 0.02); formula dyads also reported lower breastfeeding intent scores (12.0 versus 15.5, p = 0.002). Breastfeeding self-efficacy scores were similar but decreased for both groups over 1 month. At 1 month, mothers who chose formula were more likely to continue to provide breast milk to their infants (84% versus 72%). Direct breastfeeding rates were similar (72% versus 68%); of participants directly breastfeeding at 1 month, PDHM dyads were 1.5 times more likely to provide maternal expressed milk. Conclusions: Differences in maternal education, BMI, and breastfeeding intent were found between feeding groups. Results suggest an association between PDHM choice and initial breastfeeding intent and breastfeeding self-efficacy and provision of maternal expressed milk at 1 month.

BACKGROUND:Preterm infants routinely require enteral feeding via nasogastric or orogastric tubes as an alternative to oral feeding to meet their nutritional needs. Anecdotal evidence suggests variations in practice related to correct tube placement and assessment of feed intolerance.PURPOSE:To determine the current practices of enteral feeding tube placement confirmation and gastric residual (GR) aspiration of neonatal clinicians in Australia.METHODS:A cross-sectional online survey comprising 24 questions was distributed to nursing and medical health professionals working in Australian neonatal care units through 2 e-mail listservs made available by professional organizations.FINDINGS:The survey was completed by 129 clinicians. A single method was practiced by 50% of the clinicians in confirming tube placement, and most common practice was assessing the pH of GR aspirate. The majority of respondents (96%) reported that they relied on GR aspiration and clinical signs to determine feeding tolerance and subsequent decisions such as ceasing or decreasing feeds. However, the frequency of aspiration, the amount and color of aspirate considered to be normal/abnormal, and decisions on whether to replace gastric aspirate or whether aspiration should be performed during continuous tube feeding varied.IMPLICATION FOR PRACTICE:This study demonstrated considerable variability in clinical practice for enteral feeding tube placement confirmation and GR aspiration despite most respondents reporting using a unit-based clinical practice guideline. Our study findings highlight the need for not only developing evidence-based practice guidelines for safe and consistent clinical practice but also ensuring that these guidelines are followed by all clinicians.IMPLICATION FOR RESEARCH:Further research is needed to establish evidence-based methods both for enteral feeding tube placement confirmation and for the assessment of feeding intolerance during tube feeding. In addition, the reasons why evidence-based methods are not followed must be investigated.

Editor(s): Edmonds, Joyce K. PhD, MPH, RN, Perinatal Guest Editors; Weiseth, Amber L. DNP, MSN, RNC-OB, Perinatal Guest Editors; Gregory, Katherine PhD, RN, FAAN, Neonatal Editor Author Information

Leukocyte telomere length is a biomarker of aging-related health risks. Hospitalized preterm infants frequently experience elevated oxidative stress and inflammation, both of which contribute to telomere shortening. Our aim was to examine changes in telomere length during neonatal intensive care unit (NICU) hospitalization in a cohort of preterm infants <32 weeks’ gestation. We conducted a longitudinal study of 10 infants (mean gestational age 27 weeks, range 23.5 to 29, at birth). We isolated DNA from dried blood spots and used Real Time Quantitative PCR to measure relative leukocyte telomere length in triplicate at three time points for each participant. From birth to discharge, infants experienced an average decline in relative telomere length of 0.021 units per week (95% CI -0.040, -0.0020; p = 0.03), after adjustment for gestational age at birth. Our results suggest a measurable decline in telomere length during NICU hospitalization. We speculate that telomere length change may convey information about NICU exposures that carry short- and long-term health risks.