Published online December 31, 2007
PEDIATRICS Vol. 121 No. 1 January 2008, pp. 181-182 (doi:10.1542/peds.2007-3017)

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COMMENTARY

Nutritional Rehabilitation for Brain-Injured Infants: Catch-up Growth Is Good

David H. Adamkin, MD

Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky

No longer in neonatal nutrition are we focusing on just meeting nutritional needs. New questions to consider include, "Can nutrition in early life affect the patient's response to disease?" and "Does nutrition matter for long-term health and neurodevelopment?" In this issue of Pediatrics, Dabydeen et al¹ provide insight into the possibilities.

Term and preterm infants with severe neonatal encephalopathy were randomly assigned; the study included a treatment group that consisted of infants receiving 120% energy and protein intake from term through 12 months of age. Occipitofrontal circumference and axonal diameters in the corticospinal tract, estimated by transcranial magnetic stimulation, were increased in those who were receiving the higher-energy and -protein diet.

Does this study's results strictly demonstrate nutritional rehabilitation (ie, providing an intervention to ameliorate the problem after the insult), or could "programming" a stimulus or insult during a critical period of development that can have long-term or lifetime effects on an organism be playing a role here as well? Perhaps nutrient enrichment with enhanced protein might not only promote catch-up growth in a nutritionally deprived infant, but it might also exert distinct biological effects on the rapidly growing brain and influence outcome at a critical stage of development.

Growth faltering and accumulating nutrient deficiencies are common in preterm infants but are also possible in critically ill late-preterm and term infants. The accumulated nutrient deficits in these critically ill infants contribute to poor growth, including perinatal brain growth failure.^2–4 Dabydeen et al postulate that perinatal brain injury would be associated with failure to thrive in the first postnatal year because of increased energy and protein requirements from deficits accumulated during the course of neonatal intensive care.

Considerable attention has been paid to improving the nutrition of the hospitalized critically ill neonate with strategies such as early aggressive total parenteral nutrition, minimal enteral nutrition, nutrient-enriched formulas, and multinutrient fortifiers for human milk. Only recently have we focused on nutritional support after hospital discharge.⁵ The first year of life may provide an important opportunity for human somatic and brain growth to compensate for earlier deprivation.

"Catch-up" growth refers to a high velocity of physical growth to reach a constitutional growth trajectory after a reduction in growth rate.⁶ In preterm infants, poor postnatal growth is an independent factor that produces an adverse outcome.⁷ Preterm infants who maintain good growth velocity or demonstrate catch-up growth after the equivalent of term do better neurodevelopmentally; those who show a slowdown in weight gain from birth to term and/or term to 8 months’ corrected age have significant delay and neurologic deficit.⁸

For term infants randomly selected from a large birth cohort, head growth during infancy (first year of life) was the best predictor of intelligence, with surveillance out to 8 years of age.⁹ The brain volume that a child achieves by the age of 1 year helps determine later intelligence. Growth in brain volume after infancy may not compensate for poorer earlier growth.⁹

The Dabydeen et al study demonstrates that dietary intervention in a group of critically ill preterm and term infants with severe neonatal brain injury allowed catch-up growth in the short term and, hopefully, nutritional rehabilitation in the long term.¹ Infancy offers the greatest opportunity for promoting postnatal brain growth and neurodevelopmental outcome.

From this unique group of brain-injured infants who are usually excluded from such nutritional studies comes the possibility that providing nutrient enhancement and catch-up growth may also improve motor and cognitive outcomes at school age, which is when they will be studied again. Let's hope rehabilitation really works.

	FOOTNOTES

 
Accepted Oct 9, 2007.

Address correspondence to David H. Adamkin, MD, University of Louisville, Neonatal Medicine, 571 S Floyd St, Louisville, KY 40202. E-mail: david.adamkin{at}louisville.edu

The author has indicated he has no financial relationships relevant to this article to disclose.

Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.

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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics

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This Article Extract Full Text (PDF) Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Adamkin, D. H. Search for Related Content PubMed PubMed Citation Articles by Adamkin, D. H. Related Collections Office Practice Social Bookmarking                         What's this?