Very Low Birth Weight Infant, Very Preterm Maturity of Infant
Conditions
Keywords
Magnetic Resonance Imaging, Neurodevelopment, Nutrition, Fortification
Brief summary
Human milk has several well-established benefits but does not adequately meet the increased nutritional demands of the growing preterm infant, necessitating additional nutrient supplementation in a process known as fortification. In U.S. neonatal intensive care units (NICUs), human milk is primarily supplemented using standardized fortification, in which a multicomponent fortifier is added to human milk to achieve assumed nutrient content based on standard milk reference values. However, this method does not account for the significant variability in human milk composition or in preterm infant metabolism, and up to half of all very premature infants experience poor growth and malnutrition using current nutritional practices. Poor postnatal growth has adverse implications for the developing preterm brain and long-term neurodevelopment. Recent advances allow for individualized methods of human milk fortification, including adjustable and targeted fortification. Adjustable fortification uses laboratory markers of protein metabolism (BUN level) to estimate an infant's protein requirements. In targeted fortification, a milk sample is analyzed to determine its specific macronutrient and energy content, with additional macronutrient supplementation provided as needed to achieve goal values. Emerging data suggest that both methods are safe and effective for improving growth, however information on their comparable efficacy and neurodevelopmental implications are lacking, particularly using advanced quantitative brain MRI (qMRI) techniques. Through this prospective, randomized-controlled trial, the investigators will compare the impact of individualized human milk fortification on somatic growth and neurodevelopment in preterm infants. Infants will be randomized to receive one of three nutritional interventions: standardized (control group), adjustable, or targeted human milk fortification. Infants will undergo their assigned nutritional intervention until term-equivalent age or discharge home, whichever is achieved first. Brain qMRI will be performed at term-corrected age, and neurodevelopmental follow-up will be performed through 5 years of age.
Interventions
DIETARY_SUPPLEMENTStandardized Fortification
Fortification with liquid, bovine-based HMF to assumed human milk content of 24kcal/oz
DIETARY_SUPPLEMENTAdjustable Fortification
Additional liquid protein supplementation to maintain serum BUN levels within goal range (9-14mmol/dL)
Sponsors
Children's National Research Institute
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
SUPPORTIVE_CARE
Masking
SINGLE (Outcomes Assessor)
Masking description
Due to the nature of the nutritional interventions, the clinical and research teams will not be blinded to study intervention. The radiologist and research team members performing MRI interpretation, post-acquisition processing, and quantitative analysis will be blinded to study nutritional intervention arm. Similarly, teams performing neurodevelopmental follow-up will also be blinded to study nutritional intervention arm.
Intervention model description
Prospective, randomized-controlled trial comparing the impact of individualized human milk fortification on somatic growth and neurodevelopment in preterm infants randomized to receive one of three nutritional interventions: standardized (control), adjustable, or targeted human milk fortification.
Eligibility
Sex/Gender
ALL
Age
No minimum to 4 Weeks
Healthy volunteers
No
Inclusion criteria
* Birth gestational age (GA) of ≤32 weeks * Postnatal age ≤4 weeks at time of enrollment * Maternal plan to provide human milk to infant, and consent to providing donor human milk if insufficient maternal milk supply * Maternal age \> 18 years old
Exclusion criteria
* Formula feeding prior to 36 weeks PMA or discharge home (whichever achieved first), either secondary to parental preference or medical necessity * Dysmorphic features or congenital anomalies suggestive of a genetic syndrome, metabolic disorder, chromosomal abnormality, or congenital infection * Dysgenetic or major destructive brain lesions detected by head ultrasound before enrollment
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Weight Gain Velocity | Study enrollment through nutritional intervention endpoint (term-equivalent age (40 weeks PMA [postmenstrual age]) or discharge home, whichever is achieved first) | Weight gain velocity (grams per kilogram per day) |
| Length Growth Velocity | Study enrollment through nutritional intervention endpoint (term-equivalent age (40 weeks PMA [postmenstrual age]) or discharge home, whichever is achieved first) | Length growth velocity (centimeters per week) |
| Head Circumference Growth Velocity | Study enrollment through nutritional intervention endpoint (term-equivalent age (40 weeks PMA [postmenstrual age]) or discharge home, whichever is achieved first) | Head circumference growth velocity (centimeters per week) |
| Total and Regional Brain Volumes | Term-equivalent age (38 to 41 weeks postmenstrual age) | Total and regional (cortical and deep gray matter, white matter, amygdala-hippocampus, brainstem, cerebellum) brain volumes by MRI |
| Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS) | Term-equivalent age (38 to 41 weeks postmenstrual age) | Summary scores in 13 different domains (habituation, attention, handling, self-regulation, arousal, excitability, lethargy, hypertonicity, hypotonicity, non-optimal reflex, asymmetric reflex, quality of movement, stress) |
| Mullen Scales of Early Learning (MSEL) | 18 months corrected age | Composite score as well as 5 subscores: gross motor, fine motor, visual reception, receptive language, and expressive language (reported as standardized t-scores, higher score indicates a better outcome, mean standardized t-score of 50 with standard deviation of 10) |
| Wechsler Preschool and Primary Scale of Intelligence (4th edition) (WPPSI-IV) | 60 months (5 years) of age | Five primary indices: verbal comprehension, visual spatial, working memory, fluid reasoning, and processing speed (higher score indicates better performance, score range 40 to 160) |
| Differential Abilities Scale (2nd edition)-(DAS-II) | 60 months (5 years) of age | \*For children with significant delays who may be unable to reach basal scores on the WPPSI-IV Early years core battery: verbal, nonverbal, and spatial reasoning subtests (higher score indicates better performance, score range 40-170) |
Countries
United States
Contacts
Primary ContactCatherine Limperopoulos, Ph.D.
Backup ContactKatherine M. Ottolini, M.D.
Outcome results
None listed