Relative to a fetus of the same gestational age, very low birth weight (VLBW) infants are more likely to be underfed and to undergo growth restriction during their early hospital stay. The current trend towards "early and aggressive" nutritional strategies in VLBW infants aims to overcome the early nutritional deficiency and thereby boost postnatal catch-up growth, simultaneously improving long-term neurodevelopmental outcomes. Although the minimum starting amino acid (AA) dose to prevent negative nitrogen balance is well established, the upper limit and the rate of increase of early AA doses are controversial. Most randomized controlled trials show that early and high-dose (target, 3.5 to 4.9 g/kg/day) AA regimens, with or without high nonprotein calories, do not improve long-term growth and neurodevelopment. High-dose AA supplementation may lead to early metabolic disturbances and excessive or disproportionate plasma AA levels, particularly in infants of very low gestational age. Further large studies are needed to clarify the optimal strategy for early administration of parenteral AA doses in VLBW infants.
Amino Acids ; Fetus ; Gestational Age ; Growth and Development ; Humans ; Infant* ; Infant, Very Low Birth Weight* ; Length of Stay ; Malnutrition ; Nitrogen ; Parenteral Nutrition ; Plasma

Necrotizing enterocolitis (NEC) is a leading cause of morbidity and mortality among premature infants. Although the pathogenesis of NEC remains unclear, recent researches revealed several associated factors of the immature intestine, with an emphasis of delayed maturation of motor and digestive function, impairment of regulation of vascular flow and intestinal barrier function, and defective immune defense. Many clinical trials have investigated the preventive role of possible disease-modification factors, but only breast feeding and antenatal steroid were proven to decrease the incidence of NEC in meta- analyses. Recent multicenter studies demonstrated a promising outcome of probiotics supplementation in the prevention of NEC, which emphasized the role of abnormal bacterial colonization in the pathogenesis of NEC. Studies on optimal choice for surgically indicated infants with NEC (laparatomy versus primary peritoneal drainage) still remain inconclusive. As NEC is a disease with a multifactorial etiology, combinations of current evidence in practice are required to reduce the incidence of NEC.
Breast Feeding ; Colon ; Enterocolitis, Necrotizing ; Humans ; Incidence ; Infant ; Infant, Newborn ; Infant, Premature ; Intestines ; Probiotics

No abstract available.
Humans ; Infant, Newborn ; Infant, Premature ; Nutrition Assessment

Several well-designed multicenter clinical trials of therapeutic hypothermia, maintaining rectal temperature of 33-34degrees C for 72 hours in neonates suffered from perinatal asphyxia, have demonstrated both safety and efficacy of therapeutic hypothermia in improving survival and neurodevelopmental outcomes. However, issues regarding the optimal cooling method, the target temperature and the duration of the hypothermia remain unsettled. To overcome limited efficacy of therapeutic hypothermia in the subgroup of infants with severe hypoxic ischemic encephalopathy, a few promising hypothermia-combined therapies, targeting the several steps in the pathogenesis of hypoxic ischemic encephalopathy, are now under investigation. Further data on the neurodevelopmental outcome of the study population of the finished or ongoing clinical trials, during the childhood period or thereafter, are required to settle therapeutic hypothermia as "a standard of care" against perinatal asphyxia. Nationwide establishment of efficient patient referral system and intimate communication of cooling protocol between obstetricians and neonatologists will make therapeutic hypothermia in neonates more available in Korea.
Asphyxia ; Humans ; Hypothermia ; Hypoxia-Ischemia, Brain ; Infant ; Infant, Newborn ; Korea ; Referral and Consultation

Newborn infants with huge and highly vascular sacrococcygeal teratoma (SCT) are frequently subjected to renal hypoperfusion secondary to high-output cardiac failure. Any underlying renal dysfunction is a significant risk factor for the development of contrast-induced nephropathy (CIN). However, reports on CIN in infants are rare. I report here a case of a premature infant born at 28 weeks and 3 days of gestation with a huge SCT who survived preoperative embolization and surgical resection but presented with persistent non-oliguric renal failure that was suggestive of CIN. During radiological intervention, a contrast medium had been administered at about 10 times the manufacturer-recommended dose for pediatric patients. Despite hemodynamic stabilization and normalization of urine output immediately following surgery, the patient's serum creatinine and cystatin-C levels did not return to baseline until 4 months after birth. No signs of reflux nephropathy were observed in follow-up imaging studies. Dosing guidelines for the use of a contrast medium in radiological interventions should be provided for infants or young patients.
Acute Kidney Injury ; Creatinine ; Embolization, Therapeutic ; Follow-Up Studies ; Heart Failure ; Hemodynamics ; Humans ; Infant ; Infant, Newborn ; Infant, Premature* ; Parturition ; Pregnancy ; Renal Insufficiency ; Risk Factors ; Teratoma*

Persistent pulmonary hypertension of the newborn (PPHN) is a consequence of the failure of a decrease in the elevated pulmonary vascular resistance after birth. Pulmonary vasodilators, including inhaled nitric oxide (iNO), have been the mainstream of targeted therapy for PPHN, but no drugs have been proven to be effective in preterm infants with PPHN. The fetus remains hemodynamically stable despite lower arterial oxygen tension and pulmonary blood flow as compared to full-term newborns. This adaptation is due to the lower oxygen requirement and high oxygencarrying capacity of fetal circulation. The immature lungs of preterm infants are more vulnerable to reactive oxygen species, and the response of pulmonary vascular dilatation to blood oxygen tension is blunted in preterm infants. Recently, iNO has been reported to be effective in a selected group of preterm infants, such as those with prolonged preterm rupture of membrane-oligohydramnios-pulmonary hypoplasia sequence. PPHN in preterm infants, along with maximum supportive treatment based on fetal physiology and meticulous assessment of cardiovascular function, is in dire need of new treatment guidelines, including optimal dosing strategies for pulmonary vasodilators.

Persistent pulmonary hypertension of the newborn (PPHN) is a consequence of the failure of a decrease in the elevated pulmonary vascular resistance after birth. Pulmonary vasodilators, including inhaled nitric oxide (iNO), have been the mainstream of targeted therapy for PPHN, but no drugs have been proven to be effective in preterm infants with PPHN. The fetus remains hemodynamically stable despite lower arterial oxygen tension and pulmonary blood flow as compared to full-term newborns. This adaptation is due to the lower oxygen requirement and high oxygencarrying capacity of fetal circulation. The immature lungs of preterm infants are more vulnerable to reactive oxygen species, and the response of pulmonary vascular dilatation to blood oxygen tension is blunted in preterm infants. Recently, iNO has been reported to be effective in a selected group of preterm infants, such as those with prolonged preterm rupture of membrane-oligohydramnios-pulmonary hypoplasia sequence. PPHN in preterm infants, along with maximum supportive treatment based on fetal physiology and meticulous assessment of cardiovascular function, is in dire need of new treatment guidelines, including optimal dosing strategies for pulmonary vasodilators.

An abnormal plasma glucose concentration is one of the most commonly encountered metabolic problems in the intensive care of premature infants. Compared with term infants, glycogen reserves are lower in the preterm neonatal liver. Despite this, preterm infants are at a greater risk of hyperglycemia than term infants are, which is owing to comparable production rate of endogenous glucose and impaired ability to reduce glucose production rate in response to hyperglycemia. Debate continues about the normal plasma glucose concentrations and the guideline for glucose control in premature infants. Some randomized controlled trials in very low birth weight infants demonstrated little clinical benefit of tight glycemic control with early insulin therapy and higher calorie intake in terms of mortality, morbidities and growth parameters. Compared with term infants, preterm infants have limited endocrine and metabolic adaptation to hypoglycemia. In any case, hypoglycemia in premature infants should not be considered a physiologic condition. The operational criteria for intervention of hypoglycemia should be different from that in term infants. Continuous non-invasive glucose monitoring is a promising tool considering the principle of minimal handling of extremely premature infants. However, the clinical implication of abnormal glucose concentrations, previously undetected on intermittent measurements, is unclear.
Blood Glucose ; Glucose* ; Glycogen ; Homeostasis* ; Humans ; Hyperglycemia ; Hypoglycemia ; Infant ; Infant, Extremely Premature ; Infant, Newborn ; Infant, Premature* ; Infant, Very Low Birth Weight ; Insulin ; Critical Care ; Liver ; Mortality

Mimicking fetal nutrition is the goal of early paretneral nutrition (PN) in very low birth weight infants, however the limited metabolic capacity of immature organs raises concern about the toxicity of metabolites to the developing brain. Starting parenteral amino acids from the first day of life, with a rate of 1.0 to 1.5 g/kg/day, is generally recommended to prevent endogenous protein breakdown by maintaining a positive nitrogen balance. A greater of amino acid infusion rate in the range of the fetal transfer rate (3.5-4.0 g/kg/day) is well tolerated during the early days after birth in VLBWI, however the influence on growth and long-term neurodevelopmental outcome remains unknown. Limited data are available from controlled trials regarding the effects of early supplementation with lipid emulsions on neonatal morbidity. Considering the role of long-chain polyunsaturated fatty acids in the neurodevelopment, the choice of an optimal lipid emulsion should be based on the quality as well as the quantity of the lipid contents. Little is known about the clinical benefit of higher rates of glucose infusion by permitting high serum glucose level or co-administration with insulin.
Amino Acids ; Brain ; Emulsions ; Fatty Acids, Unsaturated ; Glucose ; Humans ; Infant ; Infant, Newborn ; Infant, Premature ; Infant, Very Low Birth Weight ; Insulin ; Nitrogen ; Parenteral Nutrition ; Parturition

Metabolic acidosis is commonly encountered issues in the management of critically ill neonates and especially of preterm infants during early neonatal days. In extremely premature infants, low glomerular filtration rate and immaturity of renal tubules to produce new bicarbonate causes renal bicarbonate loss. Higher intake of amino acids, relatively greater contribution of protein to the energy metabolism and mineralization process in growing bones are also responsible for higher acid load in premature infant than in adult. Despite widespread use of sodium bicarbonate in the management of severe metabolic acidosis, use of sodium bicarbonate in premature infants should be restricted to a reasonable but unproven exception such as ongoing renal loss. Despite concern about the low pH value (<7.2) which can compromise cellular metabolic function, no treatment guideline has been established regarding the management of metabolic acidosis in premature infants. Appropriately powered randomized controlled trials of base therapy to treat metabolic acidosis in critically ill newborn infants are demanding.
Acid-Base Equilibrium ; Acid-Base Imbalance ; Acidosis ; Adult ; Amino Acids ; Critical Illness ; Energy Metabolism ; Glomerular Filtration Rate ; Humans ; Hydrogen-Ion Concentration ; Infant, Extremely Premature ; Infant, Newborn ; Infant, Premature ; Sodium Bicarbonate