| Abstract |
Introduction: This study has been designed to investigate the contribution of enteral and
parenteral feeding of newborns to growth and final outcome of neonates of different
prematurity groups based on gestational age and weight (extremely low birth weight (<1000
gr) (ELBW) newborns) hospitalized in a Neonatal Intensive Care Unit (NICU). It is estimated
worldwide that 14.9 million (11.1%) of all births are preterm infants and that their
complications are responsible for 50% of neonatal deaths. Therefore, nutritional support is
one of the main interventions for the premature population and aims to establish a nutritional
balance of energy-protein intake, capable of normal growth. This is especially important, since
the period following the birth of the premature newborn is characterized by very rapid growth
rates, which are not observed in any other period of human life.
Premature birth has short-term effects on the development of the newborn as well as longterm,
intervening in the infant’s proper neurological development. For this reason, the best
nutrition strategy proposed (intestinal or parenteral, alone or supplementary), should be
established from the first day of life to maintain an optimal growth rate and prevent
catabolism with its significant negative effects on organic functions and outcome.
For the premature newborn, the ideal growth is considered to be the one that achieves growth
comparable to the endometrial rhythm of the developing fetus. However, this is not always
possible and the reasons for this may be: prematurity, respiratory distress, congenital
anomalies, hypoglycemia, lack of feeding protocol or even improper adherence to the existing
protocol. Therefore, the real challenge of modern NICU is the normal growth and
development of the newborn with the best possible outcome.
Aim of the study is to calculate the balance of energy - protein intake in premature infants
over time and to assess its impact on growth and morbidity indicators during their
hospitalization in the Neonatal Intensive Care Unit.
Material and methods: The study was carried out in NICU, Venizelio General Hospital of
Heraklion and its duration was 12 months (August 2019-August 2020). A registration form was
used which included demographic data, somatometric information both at entry and exit,
clinical data, and various nutritional parameters. Three categories of newborns were studied:
1) depending on gestational age (extremely premature <28 weeks, very premature 28-32
weeks and moderately premature 32-37 weeks) and 2) depending on their birth weight. Results: The study included a total of 84 newborns, 54 boys (64.3%), 30 girls (35.7%). Infants
<28 weeks of age had a significantly higher risk of clinical severity as estimated by the CRIB II
score (18.5%, p <0.001) and mortality (12.5%, p <0.022) compared to infants> 28 weeks of
gestation. This group of newborns needed resuscitation more frequently (87.5%), developed
RDS or sepsis, complications of PDA, NEC, BPD and longer period of mechanical ventilation
(all, p <0.001). The duration of hospitalization of the newborns differed between the groups
and showed a significant negative correlation (r = -0.85, p <0.001) with gestational age.
The days of maximum weight loss and birth weight recovery were significantly prolonged at
<28 weeks compared to 28–32-week-olds (p<0.001) and older premature infants. The onset
of enteral feeding or complete coverage of the neonate with enteral feeding as well as the
duration of parenteral feeding were significantly longer in the group <28 weeks (p <0.001).
The small preterm infants <28 weeks were initially fed at 42.9% with parenteral nutrition and
then with mixed intestinal and parenteral nutrition regimens (85.7 and 71.4%). The
cumulative energy intake through the intestinal and parenteral nutrition (kcal/kg/day) on days
7 and 14 was significantly lower than the minimum recommended for infants <32 weeks of
gestation. Also, the protein intake (gr/kg/day) was less than the minimum recommended daily
protein intake equally for all groups of gestational age (p = 0.279) on the 7th day of
hospitalization.
Upon discharge from NICU, the newborns had significantly increased weight, length and head
circumference (p <0.001) but had fallen percentiles curves in all somatometric measurements
(weight Z = -6.278, p <0.001, length Z = 3.726, p <0.001, head circumference Z = -2,184, p
<0.001). Only the sum of the administered calories on the 14th day of hospitalization reached
an independent association with a positive change in z-score entry weight - output (p=0.014)
and the small gestational age with a positive change in length z-score (p<0.001). In addition,
independent factors predicting a negative energy balance were low gestational age (AUROC
0.82, p=0.012), high CRIB II score (AUROC 0.83, p=0.009), and prolonged enteral onset for the
14 days of hospitalization, feeding, duration of parenteral nutrition (AUROC 1.0, p<0.001) and
days of mechanical ventilation (AUROC 0.89, p=0.002). Finally, independent predictors of
negative protein balance in the analysis showed (AUROC 0.66, p=0.29) and protein (AUROC
1.0, p <0.001).
Conclusion: In conclusion, the young gestational age, the severity of the disease, and the
prolonged start times of enteral feeding, the duration of parenteral nutrition and days of mechanical ventilation are negative factors in meeting the caloric and protein needs of
premature infants.
Inadequate calorie and protein intake are predictors of a negative protein balance and a
negative change in the z-score input-output weight. As a result, premature infants of younger
gestational age will have lost positions on the percentile curves and z-scores on all
somatometric measurements except head circumference.
The fact that the days of maximum weight loss and birth weight recovery are significantly
longer at <28 weeks, despite being fed from the beginning with prolonged parenteral or mixed
enteral nutrition regimens, underlines the need to design a adapted to the latest nutrition
protocol guidelines.
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