Introduction: To limit extrauterine growth restriction, recent guidelines on nutrition of preterm neonates recommended high protein intake since the first day of life (DOL). The impact of this nutritional strategy on the brain is still controversial. We aimed to evaluate the effects of protein intake on early cerebral growth in very low birth weight newborns. Materials and Methods: We performed serial cranial ultrasound (cUS) scans at 3-7 DOL and at 28 DOL in very low birth weight newborns consecutively observed in the neonatal intensive care unit. We analyzed the relation between protein intake and cerebral measurements at 28 DOL performed by cUS. Results: We enrolled 100 newborns (gestational age 29 ± 2 weeks, birth weight 1,274 ± 363 g). A significant (p < 0.05) positive correlation between enteral protein intake and biparietal diameter (r = 0.490 * *), occipital-frontal diameter (r = 0.608 * *), corpus callosum (length r = 0.293 * , genu r = 0.301 *), caudate head (right r = 0.528 * * , left r = 0.364 * *), and cerebellum (transverse diameter r = 0.440 * * , vermis height r = 0.356 * * , vermis width r = 0.377 * *) was observed at 28 DOL. Conversely, we found a significant negative correlation of protein intake given by parenteral nutrition (PN) with biparietal diameter (r = −0.524 * *), occipital-frontal diameter (r = −0.568 * *), body of corpus callosum (r = −0.276 *), caudate head (right r = −0.613 * * , left r = −0.444 * *), and cerebellum (transverse diameter r = −0.403 * * , vermis height r = −0.274 * , vermis width r = −0.462 * *) at 28 DOL. Multivariate regression analysis showed that measurements of occipital-frontal diameter, caudate head, and cerebellar vermis at 28 DOL depend positively on protein enteral intake (r = 0.402 * , r = 0.305 * , and r = 0.271 *) and negatively by protein parenteral intake (r = −0.278 * , r = −0.488 * , and r = −0.342 *). Conclusion: Brain development in neonatal life depends on early protein intake. High protein intake affects cerebral structures' measurements of preterm newborn when administered by PN. Positive impact on brain development encourages the administration of recommended protein intake mainly by enteral nutrition.
Cranial Ultrasound (cUS) may not be sensitive enough to detect subtle white matter (WM) injuries. Our study compared serial cUS with MRI at term equivalent age (TEA) to determine if it is possible to identify an ultrasound representation of subtle diffuse WM injuries such as punctate lesions (PWMLs) and diffuse excessive high signal intensity (DEHSI). Fifty-six very preterm infants were scanned sequentially from birth to TEA, an MRI was performed at TEA. Each echodensity found on cUS was classified as absent, transient (≤7 days), or prolonged (>7 days). A transient periventricular echodensity was detected in seven infants (12.5%), and a prolonged echodensity in 15 (26.8%). MRI examinations were performed in all 56 infants. No altered signal intensity was found in 18 infants (32.1%). DEHSI was detected in 14 infants (25%), and PWMLs were detected in eight babies (14.3%). Both abnormalities were found in 16 infants (28.6%). The positive predictive values of the prolonged echodensity for DEHSI and PWMLs were 86.7% and 46.7% respectively. However, a significant statistical correspondence (p=0.002, Odds Ratio 11.9) was found comparing DEHSI with cUS abnormal echodensities. Serial cUS during the neonatal period in preterm infants is essential and cannot be replaced with MRI at TEA. MRI seems to be more reliable in detecting mild or moderate WM abnormalities. However, serial cUS performed by an experienced neonatologist can provide valuable information on early WM changes such as prolonged echodensities that could potentially lead to a diffuse injury.
Current guidelines for preterm newborns recommend high energy nutrition soon after birth in order to limit growth retardation. However, long-term effects of this nutritional approach are still debated, and it has been demonstrated that cerebral growth depends on protein intake in early life. A negative impact of early high energy intake by parenteral nutrition (PN) has been reported for patients in critically ill conditions, observed in intensive care unit. We aimed at evaluating the impact of energy intake on cerebral growth in preterm neonates early in life. We included preterm newborns with gestational age < 32 weeks or birth weight (BW) < 1500 g. Measurement of cerebral structures was performed by cranial Ultrasonography (cUS) between 3 and 7 days of life (DOL, T0) and at 28 DOL (T1). We evaluated the relation between energy intake and cerebral growth in the first 28 DOL. We observed in 109 preterm newborns a significant (p < 0.05) negative correlation between energy intake received by PN and right caudate head growth (r = − 0.243*) and a positive correlation between total energy intake and transverse cerebellum diameter (r = 0.254*). Multivariate analysis showed that energy intake administered by enteral nutrition (EN), independently increased growth of left caudate head (β = 0.227*) and height cerebellar vermis (β = 0.415*), while PN independently affected growth of both right and left caudate head (β = − 0.164* and β = − 0.228*, respectively) and cerebellum transverse diameter (β = − 0.849*). The route of energy administration may exert different effects on cerebral growth in early life. High energy intake administered through EN seems to be positively correlated to cerebral growth; conversely, PN energy intake results in a poorer cerebral growth evaluated with cUS.
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