Editor's Corner

Advances in neonatal nutrition

William C. Heird, M.D.
Professor, Pediatrics—Nutrition
Guest Editor

Given the current emphasis on and interest in neonatal nutrition, it is hard to believe that as recently as 50 years ago, most small neonates were intentionally starved for the first few days of life. The eventual demonstration that infusion of a 5% glucose solution improved survival changed this practice but early nutritional management didn't improve dramatically until well after introduction of total parenteral nutrition (TPN) about 30 years ago. This, of course, was due to the difficulties of overcoming the poorly coordinated suck-swallow mechanisms, immature intestinal motility, and immature metabolic processes of these infants as well as their usual severe lung disease that necessitated mechanical ventilation, further interfering with nutrient delivery.

Though it showed early theoretical promise, TPN was not the panacea envisioned, largely because of its many unanticipated complications in the neonatal population. At the time, it was often called one of the world's largest uncontrolled clinical trials. Over the years, understanding of the basis of both the metabolic and mechanical complications of TPN has improved and these problems, for the most part, are now manageable. Accurate infusion pumps, safer methods of venous access and more optimal infusate components also are available. Concurrently, the importance of enteral nutrition has become apparent and novel routes of enteral delivery of nutrients are available. Knowledge of the nutrient needs of these infants also has improved dramatically as has knowledge of the consequences of not meeting these needs. Human milk fortifiers are available, allowing the preterm infant access to the many non-nutritional benefits of human milk while providing the additional protein, calcium, and phosphorus needed by preterm infants fed human milk.

Despite the many advances in nutritional management of preterm infants over the past 50 years, even over the past 10 years—many of them at Texas Children's Hospital and the Baylor College of Medicine's USDA/ARS Children's Nutritional Research Center—we still have a long way to go. Few of our infants weigh the same at discharge as a fetus of the same post-conceptional age and these growth deficits often persist, even into adulthood. The contribution of these deficits to the documented developmental problems of these infants is currently an active area of research. In the past two decades, the dramatic increase in survival of very immature infants has presented additional challenges, ranging from determining if nutrient needs of the tiny infants are different from those of larger infants to delivering these needs. Current research at Texas Children's is addressing those and many other questions. It is important that this continue even as we apply our still incomplete knowledge to improve the nutritional management of this exceedingly vulnerable population.