Narrator:

Welcoming Doctor Manuel Sánchez Luna, who serves as the medical director of the neonatology Division at NICU and holds a professorship in pediatrics at Hospital General Universitario Gregorio Marañon in Madrid, Spain. Doctor Sánchez Luna has contributed to over 250 publications in national and international scientific journals and books. With expertise in mechanical ventilation, bronchopulmonary dysplasia, respiratory physiology, sepsis, shock, and personalized nutrition, Doctor Sánchez Luna is dedicated to advancing neonatal care. Doctor Sánchez Luna currently serves as president of the Spanish National Society of Neonatology, and chair of the Neonatal Critical Care Section of the European Society of Pediatric and Neonatal Intensive Care, ESPNIC, playing a pivotal role in shaping neonatology practices both nationally and internationally. Please welcome Doctor Sánchez Luna.

Doctor Manuel Sánchez Luna:

Okay, good afternoon everyone. First of all, I would like to think the Mead Johnson Company and Reckitt and even more to my very good friend Nitida who invited me here with all of you today. It's an honor to to be in a hall with full of pediatrician. I am so sorry for that, but we will enjoy. And also I want to Thank Serge, because he asked me to give this talk in Spanish. So I will switch to Spanish right now. You agree? Vamos espanol.

Bueno. Well, the first question is, what is this guy doing here? If he dedicated his whole life to protecting lungs of preemies, well, there comes a moment in somebody's life that you learn, finally, that there is something that may be important to us, protection that we do with mechanical ventilation, teams as  nutrition. In the last ten years of my life, I have learned that modifying and improving nutrition of our preemies we can change the future of this children when they're adults. And I want to start with this slide that for me would be the only one that I would give today. Look, there is no better feeding for our children - preemies and sick children in the ICUs - than breast milk or mom's milk. And if you don't have this one, the milk from donors that we can give, enriched or not enriched depending on the needs of the children.

This learning has taken so much time, not only to me, but many people that are responsible for intensive care. And we forgot of how important it is, nutrition. We talked about the famous half thousand days. Don't get mad at me, but we do not talk about the first 1000 days. We talk about the first 50 weeks post menstrual because we have data that suggest that it's in these first 50 weeks post menstrual, where, if we do the things correctly, everything will go better, and if we do wrong, there would be no solution and we have to take this into account. It's timing for neurological plasticity of the newborn, especially the preemie newborn.

As you know, gestation time is the most important time that we have in our lives. Some of you have forgotten about it. During that time, we were protected and we were nurtured in a way probably perfect. No matter what scientifics say, there was no better way than what our mom did for us. But in the third trimester, it is when protein position is the most important. Look, if we are born before, when that amount of nutritional supply, especially protein, disappears, our conditions are going to be suboptimal for our development.

How can we assess this? Well, this is my first part of the presentation. When, a child is born prematurely, we have to try to continue the intrauterine growth. Well, Ehrenkranz and some other authors insist, saying, yes. Those of us that work in neonatal, you see, I know the answer is no. This is impossible. There's a gap, a falling off that speed of growth, if we use the intrauterus grafts that that baby should have, and that drop is physiological, that we live with it.

That's why it's basic that we take into account that right after birth, we have to administer what's most likely their protein support that they had in the uterus. Last recommendation haven't changed. It's still basic there. Just right after birth, we start giving protein, enough protein to keep, what we call, protein accretion, like you see, is pretty high after birth.

What's the problem? Breast milk is poor in protein right after birth, because the protein that is in the colostrum is not nutritional. It's immunogenic. The amount of milk that a baby intakes is small. So we're going to have a deficit. So years ago, we started, giving, parenteral nutrition since the birth, or units right after birth, at that same instant, we start protein supply, caloric and lipid intake. Very importantly, paying attention not only to protein intake, but also caloric as a whole. Those of us that take care of their lungs, we see that if we only maintain the protein, there is no lung development. If the calories are not adequate. There are studies, German groups that showed that just increasing the calories improves the development of the lungs. So the ratio between protein and calorie intake has to be kept since birth.

Caloric intake is important. How are we going to achieve this? Well, as I said, starting parenteral nutrition very early on, trying to keep up those 100 and 150 kilo calories per kilo, per day, that's very difficult because of the liquid volume especially, with cases that are in the limit of viability, 22, 23, 24 gestation weeks. That's extraordinarily difficult. But these are recommendations, and we have to try to follow them. Look, I tried to show this chart three years ago. We can see on the left the amount of energy that a newborn needs for different components. Right? To live in basal situation for breathing, but also, such a component, 50%, just to grow. I sometimes tell other pediatricians, colleagues that our kids don't get bigger, they just grow. I really ask them when they go to ICU, neonatal, don't get them fatter, no, just ask them to make them grow because growing is cell development. What happens when you are sick? That energy that has to be dedicated to the growth disappears, because it has to be dedicated to keeping you alive. So no matter how many calories we're giving, the child that is sick is in a situation that is totally different from the one that is healthy. And this message I want you to take home. Because on top of this one, we are going to have some of the most important considerations here.

How do we monitor the growth of our children? Well, I don't know if you made it, but I was lucky enough to know that when I was a young doctor, I'm not anymore. I look like it. But I'm not. We follow the charts that he gave us for postnatal growth. That's what we had. Today, we know that we have to use growth charts that are postnatal, done with real children that have been born and that are, out of the years, because that growth is the one that we need to use traditionally. TR Fenton, offered the best growth charts for our preemies since 2013. Also Olsen, in a group of children a little younger, administered these kind of charts. And we also we have WHO charts, but what are the ones that we have to use intrauterine, Fenton, Olsen… any it doesn't matter. What are the graphs that you use? Well, I’m not sure I have time, but think about it, because this reflection is done by me many times when we’re at our department. Look, there's big differences between ones and the others. Years ago we picked following Fenton. Population is 4 million babies in Germany, the US, Italy, Australia, Scotland and Canada. So it reflects our wide, different latitude babies from gestational ages from 22 to 50. And I want you to keep that idea in your mind up to 50 weeks. Why? Because after 50, we don't use it anymore. We changed to WHO charts or like we see Intergrowth-21.

What happens with Intergrowth-21. And I brought it because I was a part of anthropometric group in Intergrowth-21 with abiotrophia, but we made some mistakes. If Jose hears me, he's going to kill me. But it's true. We took reference intrauterine that were excellent. We have growth reference - probably the best ones - but after birth we didn't have lots of kids that were premature and we didn't have a lot of data with babies with low birth weight. So, if we use the Intergrowth-21 original chart, we're going to have a problem when we look at how kids that are low, gestational age group. That's why 2015 and 16, there were some changes to add more babies that are born very prematurely. But I have to say, like most say, we do not recommend this chart, only after week 50 post menstrual for the follow up of our kids, because we still have very little populations of very preemie kids.

I like this study very much. There's many, but I brought this one, quite big population, 600 babies, less weight than 1500 grams. Graphs are comparing Fenton and Intergrowth-21. They see how each baby is at birth in order to define, little differences. Look at the difference. If we use Intergrowth-21, prevalence is 9%. But if we use Fenton, prevalence is five. What happens? There is going to be an important percentage of children that are not going to be diagnosed at birth. If we use directly Fenton graph, but with a follow up to diagnose restriction of extra uterine growth, if we use Fenton curves, we have many more kids that have growth restriction than if we use the Intergrowth-21 curves.

What do I mean with this? Use whatever you want, but be aware of what you are using and when you compare with results from other hospitals, other countries, know how you are measuring these graphs. Well, there's a concept that is irregular growth, what they called growth faltering. How can we detect these children that start growing badly and it could have consequences short and long term. Is weight enough? Do we need to weight, head circumference at a certain point for the follow up? Well, let's try to see how, American Academy of Pediatricians tells us how to do these faltering growth. Well, they are not really clear. This is what we have. They recommend to use weight, head circumference and use Z scores when we are doing that assessment usually. And we'll see that is going to be around 36 weeks, post menstrual and discharged from the hospital, to see the kids that will have a growth problem. I admire Tanis. I'm sorry. This is his last, publication, a, month and a half ago. This is an excellent study, and it's extraordinarily provocative and has broken some barriers that we had intellectual ones. Tanis has a study in which [he] takes babies less than 1500 grams, 1,133 babies. See these minus two Z scores to define the values and to define that irregular growth, that these kids are going to have, and they do something that they haven't done. They take away neurological pathology, kids respiratory diseases and enteric colitis. So, healthy newborns. And they look at how they grow. I bring this study in four slides that I want you to take home because he changed the way we understand, faltering extrauterine growth.

Look, minus two Z scores up, doesn't have a predictive value and sensitivity is very low if a newborn is healthy. If they don't have serious diseases, very low value. Most kids that were born a good weight, they have a normal growth using W.H.O., graphs. But if we take away the kids that got sick, we do have kids that have low birth, low weight, after the gestational age, what happened? Most of those grew okay if they were not sick?

This hypothesis, rings a bell. We'll talk about it later. So, most of these children that she studies, at birth, they receive parenteral nutrition, they receive fortified maternal milk and also in a routine way, two times a week they have a dietician following up, talking about nutrition. And using this, most of these children, they catch up by three years.

Most of them, we don't have almost any child that don't catch up by three years. Kids that grow well, they have good neural development. We cannot define clearly for the ones that are small for the gestational age, when they catch up is, but most of them by three years they got there. And what does it mean? It rebates Barker’s hypothesis, that if a child is born small, they would metabolic syndrome, hypertension. Because, if a child that is born small, we treat them. Okay. Nutrition is good and they don't have diseases, that child will grow, okay, and it would be a healthy adult. Just keep this message, because not everything is lost just because you were born small for your gestational age. And on top of this, when a child grows badly, not everything is related to nutrition. There's other factors. For example, kids that don't know how to eat, kids that don't know how to swallow, kids that had more pathology, not severe, and social problems. This will interfere really in the development of the babies. What is it that we should follow in our hospitals? Let's say this is easy, at least twice a week we have to follow up the nutrition of these kids’ calorie intake and if possible, have our dietitian working with us. We have to have a longitudinal study of growth, head circumference and size. And we have to try for these children by 2 or 1 year old, are over minus two Z scores for their development. Doing this, probably, big problems will disappear, related with the growth of these children. Three words for this that we have to do regarding nutrition administration, this, famous study, when it's criticized, this is a meta-analysis comparing administration, or not, of nutrition compliments for preemie children. This systematic review, we don't see significant differences by having more nutrition. But if we look into detail these meta-analysis, we see, in fact, that the kids that had more nutritional support, they have better neuro-motor evolution at long term. That's why it is not that it's bad, it's, if anything it's better having these better nutrition. But recently, we have this review of Doctor Lucas that compared kids that after discharge have preemie formula complemented or they have the milk. And this is something interesting they took out of this meta-analysis, these two studies that were outliers that had results that were different. So when they do that, we see that the kids that were preemie that get after discharge an enriched formula for nutritional support, they grow better during the first year of life. They grow better in weight, better in size and better in head circumference.

And not only that, these children probably will evolve better medium and long term. That's why, again, nutritional support could be key for these kids to do better. I want to finish with these two comments that we sometimes forget that are important. We have stuff in our hospital that since the moment kids are stable, they start stimulating, deglution and suction. Why? Because we know that preemie kids, especially those that were a lot for a long time in ICU, they have a lot of difficulties for feeding, and that could interfere in the development. Take this into account. Not everything is nutrition, calories and protein. Then a big epidemic that we see, I'm sure you see it in your countries, the late preterm, a baby that had a C-section just because the obstetrician is good for them, and the lady, there is no hormonal stimulus. The kid goes to the hospital, there is no breastfeeding. There is formula feeding. And these kids, we know that they have more bad motor coordination. So we have to take into account that these teen children, that in some countries is up to 40% cesarean births, no reason at all. It could be a big problem in neurodevelopment just related with bad ability for these children to learn to eat and also because they're fed with formula from the beginning.

To end, two slides that are summarizing, that I would like for you to take home, at least to show that, neonatologist sometimes is a good option in these meetings. We have to get a discharge, a concept that we have at least 55% or more of our preemies go home with their moms milk. Usually, and if we can fortify it, enrich [it], there many ways of doing this. We have to see the growth trajectory. It's not enough to grow, point by point, the evolution. We have to use whatever graphic you use. But the graph that has shown, that is pertinent for children growth, we recommend Fenton up to 50 post menstrual, and then we change to Intergraowth or W.H.O. after that.

Remember comorbidities. Don't blame since the baby was born preemie, he's going to be hypertensive. We seriously doubt that concept. And remember, the less comorbidities the child, the healthier he will be as an adult. We have to see nutritional needs, not only during the hospital stay, but we have to teach them to eat a pretty often. It's important to see the slower growth and it's important to see it, not only because of the weight, but also for the length and the head circumference.

Not much more. This is what I wanted to tell you. I hope I didn't bore you. Let's hope we can see each other again some other year. Thank you so much for your attention.