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Han J, Zhang L, Zhang R, Han S, Zhu J, Hu X, Sun J, Qiu G, Li Z, Yan W, Xie L, Ye X, Gong X, Li L, Bei F, Liu C, Cao Y. Using a new human milk fortifier to optimize human milk feeding among very preterm and/or very low birth weight infants: a multicenter study in China. BMC Pediatr 2024; 24:61. [PMID: 38243173 PMCID: PMC10797784 DOI: 10.1186/s12887-024-04527-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 01/02/2024] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND Human milk fortifier (HMF) composition has been optimized recently. But clinical evidence of its safety and efficacy is limited in Chinese population. The aim of this study was to evaluate effects of a new HMF in growth, nutritional status, feeding intolerance, and major morbidities among very preterm (VPT) or very low birth weight (VLBW) infants in China. METHODS VPT/VLBW infants admitted from March 2020 to April 2021 were prospectively included in the experimental (new HMF, nHMF) group, who received a new powdered HMF as a breast milk feeding supplement during hospitalization. Infants in the control group (cHMF) admitted from January 2018 to December 2019, were retrospective included, and matched with nHMF group infants for gestational age and birth weight. They received other kinds of commercially available HMFs. Weight gain velocity, concentrations of nutritional biomarkers, incidence of major morbidities, and measures of feeding intolerance were compared between the two groups. RESULTS Demographic and clinical characteristics of infants in nHMF and cHMF groups were comparable. Weight gain velocity had no significant difference between the nHMF (14.0 ± 3.5 g/kg/d) and the cHMF group (14.2 ± 3.8 g/kg/d; P = 0.46). Incidence of morbidities, including necrotizing enterocolitis, bronchopulmonary dysplasia, retinopathy of prematurity, culture-confirmed sepsis, and feeding intolerance during hospitalization between nHMF and cHMF, were similar (all P-values > 0.05). The time to achieve full enteral feeding [13.5 (10, 21) days] in the nHMF group was significantly shorter than that in the cHMF group [17 (12, 23) days, HR = 0.67, 95%CI: 0.49, 0.92; P = 0.01]. Compared with cHMF group, the decrease of blood urea nitrogen level over time in nHMF group was smaller (β = 0.6, 95%CI:0.1, 1.0; P = 0.01). CONCLUSIONS The new HMF can promote growth of preterm infants effectively without increasing the incidence of major morbidity and feeding intolerance. It can be used feasible in Chinese VPT/VLBW infants. TRIAL REGISTRATION This study was registered on ClinicalTrials.gov (NCT04283799).
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Affiliation(s)
- Junyan Han
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, 399 Wanyuan Road, Minhang District, Shanghai, 201102, China
| | - Lan Zhang
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, 399 Wanyuan Road, Minhang District, Shanghai, 201102, China
| | - Rong Zhang
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, 399 Wanyuan Road, Minhang District, Shanghai, 201102, China
| | - Shuping Han
- Department of Pediatrics, Nanjing Maternity and Child Health Care Hospital, Women's Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, 210004, China
| | - Jianxing Zhu
- Department of Neonatology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200092, China
| | - Xuefeng Hu
- Department of Neonatology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Jianhua Sun
- Department of Neonatology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China
| | - Gang Qiu
- Department of Neonatology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200040, China
| | - Zhenghong Li
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, China
| | - Weili Yan
- Department of Clinical Epidemiology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 201102, China
| | - Lijuan Xie
- Department of Neonatology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200092, China
| | - Xiuxia Ye
- Department of Neonatology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China
| | - Xiaohui Gong
- Department of Neonatology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200040, China
| | - Liling Li
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, 399 Wanyuan Road, Minhang District, Shanghai, 201102, China
| | - Fei Bei
- Department of Neonatology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China
| | - Chan Liu
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, 399 Wanyuan Road, Minhang District, Shanghai, 201102, China
| | - Yun Cao
- Department of Neonatology, Children's Hospital of Fudan University, National Children's Medical Center, 399 Wanyuan Road, Minhang District, Shanghai, 201102, China.
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Talebiyan S, Belfort MB. Human Milk Fortification for Very Preterm Infants: Toward Optimal Nutrient Delivery, Neonatal Intensive Care Unit Growth, and Long-Term Outcomes. Clin Perinatol 2023; 50:625-641. [PMID: 37536768 DOI: 10.1016/j.clp.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Human milk is the preferred diet for very preterm infants due to short-term and long-term benefits for health and neurodevelopment. Fortification of human milk is required to deliver sufficient nutrients to attain recommended growth targets during the neonatal hospitalization. Intrinsic variability in human milk composition poses a challenge in clinical practice because some infants fail to meet recommended nutrient intakes even with existing approaches of standard (fixed-dose) and adjustable fortification. Individually targeted fortification is an emerging strategy to minimize nutrition delivery gaps through application of point-of-care human milk analysis and has potential to improve growth and related outcomes.
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Affiliation(s)
- Saharnaz Talebiyan
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, 221 Longwood Avenue BL-341, Boston, MA 02115, USA
| | - Mandy Brown Belfort
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, 221 Longwood Avenue BL-341, Boston, MA 02115, USA; Harvard Medical School, Boston, MA, USA.
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Cardoso M, Virella D, Papoila AL, Alves M, Macedo I, E Silva D, Pereira-da-Silva L. Individualized Fortification Based on Measured Macronutrient Content of Human Milk Improves Growth and Body Composition in Infants Born Less than 33 Weeks: A Mixed-Cohort Study. Nutrients 2023; 15:nu15061533. [PMID: 36986263 PMCID: PMC10052754 DOI: 10.3390/nu15061533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/19/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
The optimal method for human milk (HM) fortification has not yet been determined. This study assessed whether fortification relying on measured HM macronutrient content (Miris AB analyzer, Upsala, Sweden) composition is superior to fortification based on assumed HM macronutrient content, to optimize the nutrition support, growth, and body composition in infants born at <33 weeks' gestation. In a mixed-cohort study, 57 infants fed fortified HM based on its measured content were compared with 58 infants fed fortified HM based on its assumed content, for a median of 28 and 23 exposure days, respectively. The ESPGHAN 2010 guidelines for preterm enteral nutrition were followed. Growth assessment was based on body weight, length, and head circumference Δ z-scores, and the respective growth velocities until discharge. Body composition was assessed using air displacement plethysmography. Fortification based on measured HM content provided significantly higher energy, fat, and carbohydrate intakes, although with a lower protein intake in infants weighing ≥ 1 kg and lower protein-to-energy ratio in infants weighing < 1 kg. Infants fed fortified HM based on its measured content were discharged with significantly better weight gain, length, and head growth. These infants had significantly lower adiposity and greater lean mass near term-equivalent age, despite receiving higher in-hospital energy and fat intakes, with a mean fat intake higher than the maximum recommended and a median protein-to-energy ratio intake (in infants weighing < 1 kg) lower than the minimum recommended.
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Affiliation(s)
- Manuela Cardoso
- Nutrition Unit, Maternidade Dr. Alfredo da Costa, Centro Hospitalar Universitário de Lisboa Central, Centro Clínico Académico de Lisboa, 2890-495 Lisbon, Portugal
| | - Daniel Virella
- Research Unit, Centro Hospitalar Universitário de Lisboa Central, Centro Clínico Académico de Lisboa, 1169-045 Lisbon, Portugal
- Neonatal Intensive Care Unit, Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Centro Clínico Académico de Lisboa, 1169-045 Lisbon, Portugal
| | - Ana Luísa Papoila
- Research Unit, Centro Hospitalar Universitário de Lisboa Central, Centro Clínico Académico de Lisboa, 1169-045 Lisbon, Portugal
- Centre of Statistics and Its Applications, University of Lisbon, 1749-016 Lisbon, Portugal
| | - Marta Alves
- Research Unit, Centro Hospitalar Universitário de Lisboa Central, Centro Clínico Académico de Lisboa, 1169-045 Lisbon, Portugal
- Centre of Statistics and Its Applications, University of Lisbon, 1749-016 Lisbon, Portugal
| | - Israel Macedo
- Neonatal Intensive Care Unit, Maternidade Dr. Alfredo da Costa, Centro Hospitalar Universitário de Lisboa Central, Centro Clínico Académico de Lisboa, 2890-495 Lisbon, Portugal
| | - Diana E Silva
- Faculty of Nutrition and Food Sciences, University of Porto, 4150-180 Porto, Portugal
- CINTESIS-Center for Health Technology and Services Research, 4200-450 Porto, Portugal
| | - Luís Pereira-da-Silva
- Neonatal Intensive Care Unit, Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Centro Clínico Académico de Lisboa, 1169-045 Lisbon, Portugal
- Nutrition Lab, Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, Centro Clínico Académico de Lisboa, 1169-045 Lisbon, Portugal
- Medicine of Woman, Childhood and Adolescence Academic Area, NOVA Medical School, Universidade Nova de Lisboa, 1349-008 Lisbon, Portugal
- CHRC-Comprehensive Health Research Centre, Nutrition Group, NOVA Medical School, Universidade Nova de Lisboa, 1349-008 Lisbon, Portugal
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Effect of Targeted vs. Standard Fortification of Breast Milk on Growth and Development of Preterm Infants (≤32 Weeks): Results from an Interrupted Randomized Controlled Trial. Nutrients 2023; 15:nu15030619. [PMID: 36771325 PMCID: PMC9919428 DOI: 10.3390/nu15030619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/17/2023] [Accepted: 01/21/2023] [Indexed: 01/27/2023] Open
Abstract
Human milk is recommended for very low birth weight infants. Their nutritional needs are high, and the fortification of human milk is a standard procedure to optimize growth. Targeted fortification accounts for the variability in human milk composition. It has been a promising alternative to standard fixed-dose fortification, potentially improving short-term growth. In this trial, preterm infants (≤32 weeks of gestation) were randomized to receive human milk after standard fortification (HMF, Nutricia) or tailored fortification with modular components of proteins (Bebilon Bialko, Nutricia), carbohydrates (Polycal, Nutricia), and lipids (Calogen, Nutricia). The intervention started when preterms reached 80 mL/kg/day enteral feeds. Of the target number of 220 newborns, 39 were randomized. The trial was interrupted due to serious intolerance in five cases. There was no significant difference in velocity of weight gain during the supplementation period (primary outcome) in the tailored vs. standard fortification group: 27.01 ± 10.19 g/d vs. 25.84 ± 13.45 g/d, p = 0.0776. Length and head circumference were not significantly different between the groups. We found the feasibility of targeted fortification to be limited in neonatal intensive care unit practice. The trial was registered at clinicaltrials.gov NCT:03775785.
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Zhu J, Liu M, Xing Y. Preterm birth and human milk proteome: are we ready for individualized fortification? Curr Opin Clin Nutr Metab Care 2022; 25:216-222. [PMID: 35199659 DOI: 10.1097/mco.0000000000000824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Preterm birth is one of the most pressing clinical problems in obstetrics and neonatology worldwide. One of the most sophisticated components of human milk is the proteome and a better understanding of it can lead to precision guides for feeding preterm infants. In this review, we will examine recent research focused on the human milk proteome and individualized protein fortification of human milk. RECENT FINDINGS In both preterm and term birth, the protein content in mother's own milk dropped rapidly in the early postnatal period. Preterm milk had a higher protein content and contained different protein and endogenous peptide compositions compared with term milk. The peptides in gastrointestinal fluids of preterm infants still need further investigation. Individualized fortification is more superior to standard fortification, but it only focuses on the total protein amount. There is no data concerning the composition and posttranslational modifications of proteins and endogenous peptides with fortification and their longterm effects. SUMMARY Comprehensive identification and characterization of the human milk proteome have led to the targeted breast milk fortification theory of preterm infant feeding and has also been enriched by clinical trials. However, to achieve fortification of key proteins and/or endogenous peptides, as standard clinical practice, requires additional studies. Future research should explore the long-term effect of protein fortification and pay more attention to quality rather than quantity in relation to infant body composition and growth outcomes.
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Affiliation(s)
- Jing Zhu
- Beijing Institute of Nutritional Resources, Beijing Academy of Science and Technology
| | - Mengyuan Liu
- Department of Pediatrics, Peking University Third Hospital, Beijing, China
| | - Yan Xing
- Department of Pediatrics, Peking University Third Hospital, Beijing, China
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6
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Arman S. What are the effects of individualized diet fortification for growth and development in infants born preterm receiving human milk? A Cochrane Review summary with commentary. Dev Med Child Neurol 2021; 63:1371-1373. [PMID: 34524685 DOI: 10.1111/dmcn.15057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Sina Arman
- Department of Physical Medicine and Rehabilitation, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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7
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Using Nature to Nurture: Breast Milk Analysis and Fortification to Improve Growth and Neurodevelopmental Outcomes in Preterm Infants. Nutrients 2021; 13:nu13124307. [PMID: 34959859 PMCID: PMC8704746 DOI: 10.3390/nu13124307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 11/24/2021] [Accepted: 11/25/2021] [Indexed: 12/29/2022] Open
Abstract
Premature infants are born prior to a critical window of rapid placental nutrient transfer and fetal growth-particularly brain development-that occurs during the third trimester of pregnancy. Subsequently, a large proportion of preterm neonates experience extrauterine growth failure and associated neurodevelopmental impairments. Human milk (maternal or donor breast milk) is the recommended source of enteral nutrition for preterm infants, but requires additional fortification of macronutrient, micronutrient, and energy content to meet the nutritional demands of the preterm infant in attempts at replicating in utero nutrient accretion and growth rates. Traditional standardized fortification practices that add a fixed amount of multicomponent fortifier based on assumed breast milk composition do not take into account the considerable variations in breast milk content or individual neonatal metabolism. Emerging methods of individualized fortification-including targeted and adjusted fortification-show promise in improving postnatal growth and neurodevelopmental outcomes in preterm infants.
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8
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Pillai A, Albersheim SG, Berris K, Albert AY, Osiovich H, Elango R. Corrected fortification approach improves the protein and energy content of preterm human milk compared with standard fixed-dose fortification. Arch Dis Child Fetal Neonatal Ed 2021; 106:232-237. [PMID: 33067263 DOI: 10.1136/archdischild-2019-317503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 08/15/2020] [Accepted: 08/23/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To evaluate whether a pragmatic corrected fortification (CF) model achieves recommended target protein and calorie content of human milk (HM) for preterm infants when compared with standard fixed-dose fortification (SF). DESIGN In this prospective non-interventional study, we enrolled mothers of infants with birth weight ≤1500 g fed exclusive HM. Infants with chromosomal or intestinal disorders were excluded. A total of 405 HM samples from 29 mothers and 45 donor milk samples were analysed for macronutrient content using a real-time HM analyser. A stepwise CF model was derived based on published data on HM calorie and protein content corrected for lactation stage and milk type. We applied both models to the measured protein and calorie content for all HM samples and compared the proportion of samples achieving target nutrient requirement in each group. RESULTS Target protein and calorie content of feed was achieved in 68% of HM samples with CF, compared with 5% samples with SF model (p<0.0001). For mother's own milk, none of the samples met the target macronutrient range with SF fortification during later lactation periods (≥week 5). With SF, over 40% of infants had poor growth (decline in weight z-score ≥0.8 SD) by 8 weeks. The final feed osmolality was acceptable for all fortification steps of the CF model. CONCLUSION The proposed CF model significantly improved the final protein and calorie content of HM with acceptable osmolality. It provides a proactive option to improve nutrient intake in premature infants.
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Affiliation(s)
- Anish Pillai
- Neonatology, Surya Hospitals, Mumbai, Maharashtra, India.,Neonatal Perinatal Medicine, Department of Pediatrics, British Columbia Women's Hospital and Health Centre, Vancouver, British Columbia, Canada
| | - Susan Gail Albersheim
- Neonatal Perinatal Medicine, Department of Pediatrics, British Columbia Women's Hospital and Health Centre, Vancouver, British Columbia, Canada.,British Columbia Children's Hospital Research Institute, British Columbia Children's Hospital, Vancouver, British Columbia, Canada.,Department of Pediatrics, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Kaitlin Berris
- Neonatal Perinatal Medicine, Department of Pediatrics, British Columbia Women's Hospital and Health Centre, Vancouver, British Columbia, Canada.,Department of Pediatrics, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Arianne Y Albert
- Women's Health Research Institute, British Columbia Women's Hospital and Health Centre, Vancouver, British Columbia, Canada.,Department of Obstetrics and Gynaecology, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Horacio Osiovich
- Neonatal Perinatal Medicine, Department of Pediatrics, British Columbia Women's Hospital and Health Centre, Vancouver, British Columbia, Canada.,British Columbia Children's Hospital Research Institute, British Columbia Children's Hospital, Vancouver, British Columbia, Canada.,Department of Pediatrics, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Rajavel Elango
- Neonatal Perinatal Medicine, Department of Pediatrics, British Columbia Women's Hospital and Health Centre, Vancouver, British Columbia, Canada .,British Columbia Children's Hospital Research Institute, British Columbia Children's Hospital, Vancouver, British Columbia, Canada.,Department of Pediatrics, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada.,Women's Health Research Institute, British Columbia Women's Hospital and Health Centre, Vancouver, British Columbia, Canada
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Abstract
Human milk is the preferred enteral diet for preterm infants. It provides macronutrients, micronutrients, and bioactive factors that support physical growth and neurodevelopment. Challenges of the human milk diet include the variability in its composition and a need for fortification to mirror placental nutrient delivery and prevent extrauterine growth restriction. Various strategies exist to attain target nutrient provision and optimize growth, including leveraging new technology for point-of-care human milk analysis. When maternal milk is unavailable or in short supply, pasteurized donor human milk is the preferred alternative. Infants fed donor milk may have slower weight gain than those fed exclusively maternal milk or formula, whereas infants fed fortified maternal milk have similar weight gain to preterm formula-fed infants. Future directions include more rigorous characterization of the variation in human milk, further investigation of the clinical benefits of non-nutrient bioactive factors in milk, and novel approaches to optimize fortification.
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Affiliation(s)
- Margaret L Ong
- Division of Newborn Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Mandy Brown Belfort
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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10
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Cardoso M, Virella D, Macedo I, Silva D, Pereira-da-Silva L. Customized Human Milk Fortification Based on Measured Human Milk Composition to Improve the Quality of Growth in Very Preterm Infants: A Mixed-Cohort Study Protocol. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18020823. [PMID: 33477964 PMCID: PMC7835734 DOI: 10.3390/ijerph18020823] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/16/2021] [Accepted: 01/18/2021] [Indexed: 12/11/2022]
Abstract
Adequate nutrition of very preterm infants comprises fortification of human milk (HM), which helps to improve their nutrition and health. Standard HM fortification involves a fixed dose of a multi-nutrient HM fortifier, regardless of the composition of HM. This fortification method requires regular measurements of HM composition and has been suggested to be a more accurate fortification method. This observational study protocol is designed to assess whether the target HM fortification method (contemporary cohort) improves the energy and macronutrient intakes and the quality of growth of very preterm infants, compared with the previously used standard HM fortification (historical cohorts). In the contemporary cohort, a HM multi-nutrient fortifier and modular supplements of protein and fat are used for HM fortification, and the enteral nutrition recommendations of the European Society for Paediatric Gastroenterology Hepatology and Nutrition for preterm infants will be considered. For both cohorts, the composition of HM is assessed using the Miris Human Milk analyzer (Uppsala, Sweden). The quality of growth will be assessed by in-hospital weight, length, and head circumference growth velocities and a single measurement of adiposity (fat mass percentage and fat mass index) performed just after discharge, using the air displacement plethysmography method (Pea Pod, Cosmed, Italy). ClinicalTrials.gov registration number: NCT04400396.
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Affiliation(s)
- Manuela Cardoso
- Nutrition Unit, Maternidade Dr. Alfredo da Costa, Centro Hospitalar Universitário de Lisboa Central, 2890-495 Lisbon, Portugal;
| | - Daniel Virella
- Research Unit, Centro Hospitalar Universitário de Lisboa Central, 1169-045 Lisbon, Portugal;
- Neonatal Intensive Care Unit, Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, 1169-045 Lisbon, Portugal
| | - Israel Macedo
- Neonatal Intensive Care Unit, Maternidade Dr. Alfredo da Costa, Centro Hospitalar Universitário de Lisboa Central, 2890-495 Lisbon, Portugal;
| | - Diana Silva
- Faculdade de Ciências de Nutrição e da Alimentação, Universidade do Porto, 4150-180 Porto, Portugal;
| | - Luís Pereira-da-Silva
- Neonatal Intensive Care Unit, Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, 1169-045 Lisbon, Portugal
- Nutrition Lab., Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, 1169-045 Lisbon, Portugal
- Comprehensive Health Research Centre (CHRC), Medicine of Woman, Childhood and Adolescence, NOVA Medical School, Universidade Nova de Lisboa, 1349-008 Lisbon, Portugal
- Correspondence: ; Tel.: +351-917-235-528
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Chen MJ, Pan NX, Wang XQ, Yan HC, Gao CQ. Methionine promotes crop milk protein synthesis through the JAK2-STAT5 signaling during lactation of domestic pigeons (Columba livia). Food Funct 2020; 11:10786-10798. [PMID: 33232416 DOI: 10.1039/d0fo02257h] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Crop milk is the sole source of nutrition that sustains young pigeons (squabs) throughout growth and development. Protein accounts for approximately 55% of the nutrients in crop milk; however, its regulation mechanism remains unclear. In our study, three experiments were conducted to investigate the possible underlying mechanism of crop milk protein synthesis and nutritional interventions. Isobaric tagging for relative and absolute quantification (iTRAQ) analysis found that the Janus activated kinase (JAK)/signal transducers and activators of transcription (STAT) pathway was significantly up-regulated in breeding pigeons during lactation compared to non-breeding pigeons. Moreover, the serum prolactin (PRL) levels increased, and the protein expression of the PRL receptor (PRLR)/JAK2/STAT5 pathway was significantly up-regulated during lactation. The serum PRL, the PRLR/JAK2/STAT5 pathway, the crop milk protein synthesis, and the squab growth performance were inhibited by bromocriptine mesylate injection, a PRL-specific inhibitor. In addition, dietary supplementation with 0.30% dl-methionine or dl-methionine-dl-methionine (especially 0.30% dl-methionine-dl-methionine), significantly increased serum PRL levels and PRLR/JAK2/STAT5 activity, and improved the crop milk protein synthesis. In conclusion, our results demonstrated that the PRL-induced PRLR/JAK2/STAT5 signaling pathway plays a vital regulatory role in crop milk protein synthesis, and 0.30% dl-methionine-dl-methionine is superior to dl-methionine in promoting crop milk protein synthesis.
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Affiliation(s)
- Meng-Jie Chen
- College of Animal Science, South China Agricultural University/Guangdong Provincial Key Laboratory of Animal Nutrition Control/Key Laboratory of Chicken Genetics, Breeding and Reproduction, Ministry of Agriculture, Guangzhou 510642, China.
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Fabrizio V, Trzaski JM, Brownell EA, Esposito P, Lainwala S, Lussier MM, Hagadorn JI. Individualized versus standard diet fortification for growth and development in preterm infants receiving human milk. Cochrane Database Syst Rev 2020; 11:CD013465. [PMID: 33226632 PMCID: PMC8094236 DOI: 10.1002/14651858.cd013465.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Human milk as compared to formula reduces morbidity in preterm infants but requires fortification to meet their nutritional needs and to reduce the risk of extrauterine growth failure. Standard fortification methods are not individualized to the infant and assume that breast milk is uniform in nutritional content. Strategies for individualizing fortification are available; however it is not known whether these are safe, or if they improve outcomes in preterm infants. OBJECTIVES To determine whether individualizing fortification of breast milk feeds in response to infant blood urea nitrogen (adjustable fortification) or to breast milk macronutrient content as measured with a milk analyzer (targeted fortification) reduces mortality and morbidity and promotes growth and development compared to standard, non-individualized fortification for preterm infants receiving human milk at < 37 weeks' gestation or at birth weight < 2500 grams. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 9), in the Cochrane Library; Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions(R); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL), on September 20, 2019. We also searched clinical trials databases and the reference lists of retrieved articles for pertinent randomized controlled trials (RCTs) and quasi-randomized trials. SELECTION CRITERIA We considered randomized, quasi-randomized, and cluster-randomized controlled trials of preterm infants fed exclusively breast milk that compared a standard non-individualized fortification strategy to individualized fortification using a targeted or adjustable strategy. We considered studies that examined any use of fortification in eligible infants for a minimum duration of two weeks, initiated at any time during enteral feeding, and providing any regimen of human milk feeding. DATA COLLECTION AND ANALYSIS Data were collected using the standard methods of Cochrane Neonatal. Two review authors evaluated the quality of the studies and extracted data. We reported analyses of continuous data using mean differences (MDs), and dichotomous data using risk ratios (RRs). We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS Data were extracted from seven RCTs, resulting in eight publications (521 total participants were enrolled among these studies), with duration of study interventions ranging from two to seven weeks. As compared to standard non-individualized fortification, individualized (targeted or adjustable) fortification of enteral feeds probably increased weight gain during the intervention (typical mean difference [MD] 1.88 g/kg/d, 95% confidence interval [CI] 1.26 to 2.50; 6 studies, 345 participants), may have increased length gain during the intervention (typical MD 0.43 mm/d, 95% CI 0.32 to 0.53; 5 studies, 242 participants), and may have increased head circumference gain during the intervention (typical MD 0.14 mm/d, 95% CI 0.06 to 0.23; 5 studies, 242 participants). Compared to standard non-individualized fortification, targeted fortification probably increased weight gain during the intervention (typical MD 1.87 g/kg/d, 95% CI 1.15 to 2.58; 4 studies, 269 participants) and may have increased length gain during the intervention (typical MD 0.45 mm/d, 95% CI 0.32 to 0.57; 3 studies, 166 participants). Adjustable fortification probably increased weight gain during the intervention (typical MD 2.86 g/kg/d, 95% CI 1.69 to 4.03; 3 studies, 96 participants), probably increased gain in length during the intervention (typical MD 0.54 mm/d, 95% CI 0.38 to 0.7; 3 studies, 96 participants), and increased gain in head circumference during the intervention (typical MD 0.36 mm/d, 95% CI 0.21 to 0.5; 3 studies, 96 participants). We are uncertain whether there are differences between individualized versus standard fortification strategies in the incidence of in-hospital mortality, bronchopulmonary dysplasia, necrotizing enterocolitis, culture-proven late-onset bacterial sepsis, retinopathy of prematurity, osteopenia, length of hospital stay, or post-hospital discharge growth. No study reported severe neurodevelopmental disability as an outcome. One study that was published after our literature search was completed is awaiting classification. AUTHORS' CONCLUSIONS We found moderate- to low-certainty evidence suggesting that individualized (either targeted or adjustable) fortification of enteral feeds in very low birth weight infants increases growth velocity of weight, length, and head circumference during the intervention compared with standard non-individualized fortification. Evidence showing important in-hospital and post-discharge clinical outcomes was sparse and of very low certainty, precluding inferences regarding safety or clinical benefits beyond short-term growth.
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Affiliation(s)
- Veronica Fabrizio
- Division of Neonatology, Connecticut Children's, Hartford, CT, USA
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Jennifer M Trzaski
- Division of Neonatology, Connecticut Children's, Hartford, CT, USA
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Elizabeth A Brownell
- School of Nursing, University of Texas Health Science Center, San Antonio, TX, USA
- Department of Pediatrics, University of Texas Health Science Center, San Antonio, Texas, USA
| | | | - Shabnam Lainwala
- Division of Neonatology, Connecticut Children's, Hartford, CT, USA
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Mary M Lussier
- Division of Neonatology, Connecticut Children's, Hartford, CT, USA
| | - James I Hagadorn
- Division of Neonatology, Connecticut Children's, Hartford, CT, USA
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT, USA
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13
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Gao C, Miller J, Collins CT, Rumbold AR. Comparison of different protein concentrations of human milk fortifier for promoting growth and neurological development in preterm infants. Cochrane Database Syst Rev 2020; 11:CD007090. [PMID: 33215474 PMCID: PMC8092673 DOI: 10.1002/14651858.cd007090.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Human milk alone may provide inadequate amounts of protein to meet the growth requirements of preterm infants because of restrictions in the amount of fluid they can tolerate. It has become common practice to feed preterm infants with breast milk fortified with protein and other nutrients but there is debate about the optimal concentration of protein in commercially available fortifiers. OBJECTIVES To compare the effects of different protein concentrations in human milk fortifier, fed to preterm infants, on growth and neurodevelopment. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search CENTRAL (2019, Issue 8), Ovid MEDLINE and CINAHL on 15 August 2019. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA We included all published and unpublished randomised, quasi-randomised and cluster-randomised trials comparing two different concentrations of protein in human milk fortifier. We included preterm infants (less than 37 weeks' gestational age). Participants may have been exclusively fed human milk or have been supplemented with formula. The concentration of protein was classified as low (< 1g protein/100 mL expressed breast milk (EBM)), moderate (≥ 1g to < 1.4g protein/100 mL EBM) or high (≥ 1.4g protein/100 mL EBM). We excluded trials that compared two protein concentrations that fell within the same category. DATA COLLECTION AND ANALYSIS We undertook data collection and analyses using the standard methods of Cochrane Neonatal. Two review authors independently evaluated trials. Primary outcomes included growth, neurodevelopmental outcome and mortality. Data were synthesised using risk ratios (RR), risk differences and mean differences (MD), with 95% confidence intervals (CI). We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS We identified nine trials involving 861 infants. There is one trial awaiting classification, and nine ongoing trials. The trials were mostly conducted in infants born < 32 weeks' gestational age or < 1500 g birthweight, or both. All used a fortifier derived from bovine milk. Two trials fed infants exclusively with mother's own milk, three trials gave supplementary feeds with donor human milk and four trials supplemented with preterm infant formula. Overall, trials were small but generally at low or unclear risk of bias. High versus moderate protein concentration of human milk fortifier There was moderate certainty evidence that a high protein concentration likely increased in-hospital weight gain compared to moderate concentration of human milk fortifier (MD 0.66 g/kg/day, 95% CI 0.51 to 0.82; trials = 6, participants = 606). The evidence was very uncertain about the effect of high versus moderate protein concentration on length gain (MD 0.01 cm/week, 95% CI -0.01 to 0.03; trials = 5, participants = 547; very low certainty evidence) and head circumference gain (MD 0.00 cm/week, 95% CI -0.01 to 0.02; trials = 5, participants = 549; very low certainty evidence). Only one trial reported neonatal mortality, with no deaths in either group (participants = 45). Moderate versus low protein concentration of human milk fortifier A moderate versus low protein concentration fortifier may increase weight gain (MD 2.08 g/kg/day, 95% CI 0.38 to 3.77; trials = 2, participants = 176; very low certainty evidence) with little to no effect on head circumference gain (MD 0.13 cm/week, 95% CI 0.00 to 0.26; I² = 85%; trials = 3, participants = 217; very low certainty evidence), but the evidence is very uncertain. There was low certainty evidence that a moderate protein concentration may increase length gain (MD 0.09 cm/week, 95% CI 0.05 to 0.14; trials = 3, participants = 217). Only one trial reported mortality and found no difference between groups (RR 0.48, 95% CI 0.05 to 5.17; participants = 112). No trials reported long term growth or neurodevelopmental outcomes including cerebral palsy and developmental delay. AUTHORS' CONCLUSIONS Feeding preterm infants with a human milk fortifier containing high amounts of protein (≥ 1.4g/100 mL EBM) compared with a fortifier containing moderate protein concentration (≥ 1 g to < 1.4 g/100 mL EBM) results in small increases in weight gain during the neonatal admission. There may also be small increases in weight and length gain when infants are fed a fortifier containing moderate versus low protein concentration (< 1 g protein/100 mL EBM). The certainty of this evidence is very low to moderate; therefore, results may change when the findings of ongoing studies are available. There is insufficient evidence to assess the impact of protein concentration on adverse effects or long term outcomes such as neurodevelopment. Further trials are needed to determine whether modest increases in weight gain observed with higher protein concentration fortifiers are associated with benefits or harms to long term growth and neurodevelopment.
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Affiliation(s)
- Chang Gao
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Jacqueline Miller
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Carmel T Collins
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, Australia
- Discipline of Paediatrics, Adelaide Medical School, The University of Adelaide, Adelaide, Australia
| | - Alice R Rumbold
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, Australia
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Parat S, Raza P, Kamleh M, Super D, Groh-Wargo S. Targeted Breast Milk Fortification for Very Low Birth Weight (VLBW) Infants: Nutritional Intake, Growth Outcome and Body Composition. Nutrients 2020; 12:nu12041156. [PMID: 32326177 PMCID: PMC7230830 DOI: 10.3390/nu12041156] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/09/2020] [Accepted: 04/17/2020] [Indexed: 01/09/2023] Open
Abstract
Despite improvements in nutritional management, preterm infants continue to face high rates of postnatal growth restriction. Because variability in breast milk composition may result in protein and energy deficits, targeted fortification has been advocated. We conducted an interventional study to compare body composition and growth outcomes of very low birth weight infants fed targeted protein-fortified human milk (HM) with those fed standard fortified HM. If mother’s own milk was not available, donor milk was used. Weekly analysis of HM with mid-infrared spectroscopy was conducted and additional protein was added to the fortified HM to ensure a protein intake of 4 g/kg/day. Weekly anthropometric measurements were done. Prior to discharge or at 37 weeks, corrected age skinfold thickness (SFT) measurements as well as body composition measurement using air displacement plethysmography were done. Among 36 preterm infants enrolled, those in the targeted group (n = 17) received more protein and had a larger flank SFT at study end than those in the standard group (n = 19). A pilot post-hoc analysis of subjects having at least 30 intervention days showed a 3% higher fat-free mass in the targeted group. Use of a targeted fortification strategy resulted in a higher protein intake and fat-free mass among those receiving longer intervention.
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Affiliation(s)
- Sumesh Parat
- Department of Pediatrics at MetroHealth Medical Center, Cleveland, OH 44109, USA; (D.S.); (S.G.-W.)
- Department of Pediatrics at Texas Tech University Health Sciences Center, Amarillo, TX 79106, USA
- Correspondence: ; Tel.: +806-414-9575
| | - Praneeta Raza
- Neurological Institute, Cleveland Clinic, Cleveland, OH 44106, USA;
| | - May Kamleh
- Health Economics and Outcomes Research, Covance Market Access, Houston, TX 77018, USA;
| | - Dennis Super
- Department of Pediatrics at MetroHealth Medical Center, Cleveland, OH 44109, USA; (D.S.); (S.G.-W.)
| | - Sharon Groh-Wargo
- Department of Pediatrics at MetroHealth Medical Center, Cleveland, OH 44109, USA; (D.S.); (S.G.-W.)
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