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Background Growth in preterm infants is compromised during the transition phase of nutrition, when parenteral nutrition (PN) volumes are weaned with advancing enteral nutrition (EN) feeds, likely due to suboptimal nutrient intakes during this time. We implemented new PN guidelines designed to maintain optimal nutrient intakes during the transition phase and compared growth outcomes of this cohort with a control group. Materials and Methods A chart review was conducted on infants born <32 weeks’ gestation, before (control group) and after (study group) a new transition PN protocol was implemented in the neonatal intensive care unit. Weight parameters and nutrient intakes were calculated for the transition phase and compared between the 2 groups. Results Demographic and clinical characteristics of the 2 groups were comparable except for higher rates of sepsis in control group. Weight-for-age z scores at birth, at 1 week of life, and at the start of the transition phase were similar. At the end of the transition phase, infants in the study group had significantly higher z scores compared with the control group, even when corrected for sepsis, a difference that persisted at 35 weeks’ gestation. During the transition phase, study infants gained 16.1 ± 4.6 g/kg/d compared with 13.2 ± 5.4 g/kg/d in control group (P < .001). Similar results were observed in the subset of expressed breastmilk–only fed infants (15.9 ± 4.6 g/kg/d in the study group compared with 13.2 ± 5.4 g/kg/d in the control group, P < .004). Conclusion Optimizing nutrition by the use of concentrated PN during the transition phase to maintain appropriate nutrient intakes improves growth rates in preterm infants.

Growth was compromised during the transitional phase, likely related to decreased protein intake. Optimizing protein provision while PN is weaned is an important strategy to prevent postnatal growth failure.

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Citrulline is a non-protein amino acid produced almost exclusively by the gut and present only in small amounts in the diet. Since the gut is the main source of citrulline, it could be used as a potential biomarker of intestinal function. Necrotizing Enterocolitis is an intestinal dysfunction in neonates leading to significant morbidity and mortality. This review discusses the various aspects of intestinal injury and the association of citrulline with bowel disorders, as well as recent developments with citrulline in the pediatric population. As citrulline is directly related to small bowel length, it has been recently shown that its levels are an efficient marker when the active mass of the bowel is affected. This could be used as a prognostic marker for parenteral nutrition weaning and development of enteral tolerance. Lower levels of citrulline are found in preterm neonates with necrotizing enterocolitis and such neonates demonstrate a more prolonged course of the disease. The concomitant increase in citrulline levels along with clinical improvement in neonates and progression of enteral feeds suggest that citrulline levels may be a sensitive marker of intestinal recovery. Studies have shown that citrulline levels are well correlated with the length of the bowel as well as intestinal function. Citrulline levels used as a sensitive biomarker for intestinal absorptive function would be clinically useful in diagnosis of necrotizing enterocolitis and detection of bowel function and recovery from intestinal disorders such as necrotizing enterocolitis, although more studies are needed in newborns affected with these diseases.

Objective Citrulline synthesized by healthy enterocytes and decreases with injury. This work aimed to study plasma citrulline concentrations (CITs) as a biomarker to differentiate among infants presenting with early nonspecific signs and symptoms of necrotizing enterocolitis (NEC) with those who will develop NEC. Further to study the correlation between posttreatment CIT with time to full feeds (TTFF) and length of stay (LOS). Study Design This is a prospective study which included infants < 32 weeks gestational age (GA) with 9 infants each in Group 1 (stage 2/3 NEC), Group 2 (with stage 1 NEC-like presentation), and Group 3 (healthy GA-matched infants). CIT was measured in Groups 1 and 2 within 24 hours of presentation and again in Group 1 after treatment. Results The three groups were similar in clinical characteristics. Median CIT (µmol/L) in Group 1 (15.4 [interquartile range, IQR: 7.3–18.0]) was lower than Group 2 (22.2 [IQR: 18.3–27.3], p = 0.02) and Group 3 (24.9 [IQR: 19.8–31.9], p = 0.009). Posttreatment CIT in Group 1 did not correlate with TTFF (r = 0.15; p = 0.69) and LOS (r =  − 0.33; p = 0.38). Conclusion CIT was lower in infants with NEC as compared with healthy controls and those infants with nonspecific signs of NEC. CIT after treatment does not correlate with TTFF and LOS. Key Points

Background: Necrotizing enterocolitis (NEC) predominantly affects preterm infants and is associated with high mortality and morbidity. There is no composite scoring tool that predicts the severity of NEC in preterm infants early in the disease process before it is established. Methods: A retrospective chart review was performed on NEC cases (n = 41) defined as infants who developed NEC stage ≥ 2 with pneumatosis intestinalis, and controls (n = 41) defined as infants with NEC stage 1, to develop a scoring tool that utilized the preterm infant's clinical status, feeding practices, radiographic and laboratory findings at set time-points (7 days, 2 days and 24 and 12 hours) before the suspicion of NEC to predict the severity of NEC. Repeated measures analysis along with sensitivity, specificity and area under curve were measured to compare the composite risk score between cases and controls. Results: The composite risk score was higher among the cases at 24 hours (2.73 ± 0.20 vs. 2.20 ± 0.20, p < .05) and 12 hours (4.20 ± 0.22 vs. 2.50 ± 0.22, p < .001) but not on 2 day (2.37 ± 0.17 vs. 2.18 ± 0.17, p = .42) prior to the suspicion of NEC to predict the severity of the disease. Feeding practices, gastric residuals, and laboratory signs of inflammation were main determinants of the final score. The most discriminatory score to differentiate between NEC stage 1 and NEC stage 2 and 3 was ≤ 2. Conclusions: This scoring system is easy to use as it utilizes normally collected data and can predict the severity of the disease enabling the physician to make decisions regarding appropriate timing of correct treatment. Further larger prospective studies are required to validate this pilot study describing NEC severity prediction tool.