OBJECTIVES The goals of this study were to describe nutritional practices in the first month of life for a large cohort of extremely low gestational age newborns and to determine the impact of these nutritional practices on growth velocity over the same period. METHODS The sample included 1187 infants born at 23 weeks to 27 weeks of gestation, at 14 institutions, between 2002 and 2004. Inclusion criteria included survival until day 28 and weight information for both day 7 and day 28. Growth velocity, expressed as grams per kilogram per day (g/kg/day), was calculated for the interval between days 7 and 28. Nutritional practices during the first week and on days 14, 21, and 28 were compared to current nutritional guidelines in the literature. Multivariable logistic regression models estimated the contribution of limited nutrition to limited growth velocity. RESULTS Protein and fat delivery approximated current nutritional recommendations while carbohydrate and total caloric delivery did not. Despite this, growth velocity of our study infants exceeded the current guideline of 15 g/kg/day. Nevertheless, we found extrauterine growth restriction (i.e., weight for gestational age below the 10th centile) in 75% of infants at 28 days, as compared to only 18% at birth. A growth velocity of 20-30 g/kg/day was associated with infants' maintaining or exceeding their birth weight Z-score, with rates in the upper range for the gestationally youngest infants. Early (day 7) nutritional practices were positively associated with growth velocity measured between days 7 and 28. CONCLUSION The early provision of nutrients is an important determinant of postnatal growth. Extrauterine growth restriction remains high in extremely premature infants even when they achieve a growth velocity rate within current guidelines.

Objective The aim of the study was to prospectively determine risk factors for the development of parenteral nutrition–associated liver disease (PNALD) in infants who underwent surgery for necrotizing enterocolitis (NEC), the most common cause of intestinal failure in children. Patients and Methods From February 2004 to February 2007, we diagnosed 464 infants with NEC, of whom 180 had surgery. One hundred twenty-seven patients were available for full analysis. PNALD was defined as serum direct bilirubin ≥2 mg/dL or ALT ≥2× the upper limit of normal in the absence of sepsis after ≥14 days of exposure to PN. Median Results Median gestational age was 26 weeks and 68% were boys. Seventy percent of the cohort developed PNALD and the incidence of PNALD varied significantly across the 6 study sites, ranging from 56% to 85% (P=0.05). Multivariable logistic regression analysis identified small-bowel resection or creation of jejunostomy (odds ratio [OR] 4.96, 95% confidence interval [CI] 1.97–12.51, P = 0.0007) and duration of PN in weeks (OR 2.37, 95% CI 1.56–3.60, P < 0.0001) as independent risk factors for PNALD. Preoperative exposure to PN was also associated with the development of PNALD; the risk of PNALD was 2.6 (95% CI 1.5–4.7; P = 0.001) times greater in patients with ≥4 weeks of preoperative PN compared with those with less preoperative PN use. Breast milk feedings, episodes of infection, and gestational age were not related to the development of PNALD. Conclusions The incidence of PNALD is high in infants with NEC undergoing surgical treatment. Risk factors for PNALD are related to signs of NEC severity, including the need for small-bowel resection or proximal jejunostomy, as well as longer exposure to PN. Identification of these and other risk factors can help in the design of clinical trials for the prevention and treatment of PNALD and for clinical assessment of patients with NEC and prolonged PN dependence.

Objective To determine risk factors for intestinal failure (IF) in infants undergoing surgery for necrotizing enterocolitis (NEC). Study design Infants were enrolled in a multicenter prospective cohort study. IF was defined as the requirement for parenteral nutrition for ≥ 90 days. Logistic regression was used to identify predictors of IF. Results Among 473 patients enrolled, 129 had surgery and had adequate follow-up data, and of these patients, 54 (42%) developed IF. Of the 265 patients who did not require surgery, 6 (2%) developed IF (OR 31.1, 95% CI, 12.9 –75.1, P < .001). Multivariate analysis identified the following risk factors for IF: use of parenteral antibiotics on the day of NEC diagnosis (OR = 16.61, P = .022); birth weight < 750 grams, (OR = 9.09, P < .001); requirement for mechanical ventilation on the day of NEC diagnosis (OR = 6.16, P = .009); exposure to enteral feeding before NEC diagnosis (OR=4.05, P = .048); and percentage of small bowel resected (OR = 1.85 per 10 percentage point greater resection, P = .031). Conclusion The incidence of IF among infants undergoing surgical treatment for NEC is high. Variables characteristic of severe NEC (low birth weight, antibiotic use, ventilator use, and greater extent of bowel resection) were associated with the development of IF.

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