Arachidonic and docosahexaenoic acid supplementation and brain maturation in preterm infants; a double blind RCT

A review on lipid inclusion in preterm formula: Characteristics, nutritional support, challenges, and future perspectives

The lack of nutrient accumulation during the last trimester and the physiological immaturity at birth make nutrition for preterm infants a significant challenge. Lipids are essential for preterm infant growth, neurodevelopment, immune function, and intestinal health. However, the inclusion of novel lipids in preterm formulas has rarely been discussed. This study discusses specific lipid recommendations for preterm infants according to authoritative legislation based on their physiological characteristics. The gaps in lipid composition, such as fatty acids, triacylglycerols, and complex lipids, between preterm formulas and human milk have been summarized. The focus of this study is mainly on the vital roles of lipids in nutritional support, including long-chain polyunsaturated fatty acids, structural lipids, milk fat global membrane ingredients, and other minor components. These lipids have potential applications in preterm formulas for improving lipid absorption, regulating lipid metabolism, and protecting against intestinal inflammation. The lipidome and microbiome can be used to provide adequately powered evidence of the effects of lipids. This study proposes nutritional strategies for preterm infants and suggests approaches to enhance their lipid quality in preterm formula.

Nutrition in Early Life and Its Impact Through the Life Course

The term "early life" refers to the period spanning from the fetal stage to the age of two years after birth, encompassing a total duration of approximately 1000 days [...].

Photobiota of the Tropical Red Sea: Fatty Acid Profile Analysis and Nutritional Quality Assessments

Photosynthetic organisms are primary sources of marine-derived molecules, particularly ω3 fatty acids (FAs), which influence the quality of marine foods. It is reported that tropical organisms possess lower FA nutritional quality than those from colder oceans. However, the high biodiversity known for tropical areas may help compensate for this deficiency by producing a high diversity of molecules with nutritional benefits for the ecosystem. Here we addressed this aspect by analyzing the FA profiles of 20 photosynthetic organisms from the salty and warm Red Sea, a biodiversity hot spot, including cyanobacteria, eukaryotic microalgae, macroalgae, mangrove leaves, as well as three selected reef's photosymbiotic zooxanthellate corals and jellyfish. Using direct transesterification, gas chromatography-mass spectrometry, FA absolute quantification, and nutritional indexes, we evaluated their lipid nutritional qualities. We observed interspecific and strain-specific variabilities in qualities, which the unique environmental conditions of the Red Sea may help to explain. Generally, eukaryotic microalgae exhibited the highest nutritional quality. The previously unanalyzed diatoms Leyanella sp. and Minutocellus sp. had the highest eicosapentaenoic acid (EPA) contents. The bioprospected Red Sea photobiota exhibited pharmaceutical and nutraceutical potential. By sourcing and quantifying these bioactive compounds, we highlight the untapped rich biodiversity of the Red Sea and showcase opportunities to harness these potentials.

Harmonizing multisite neonatal diffusion-weighted brain MRI data for developmental neuroscience

Large diffusion-weighted brain MRI (dMRI) studies in neonates are crucial for developmental neuroscience. Our aim was to investigate the utility of ComBat, an empirical Bayes tool for multisite harmonization, in removing site effects from white matter (WM) dMRI measures in healthy infants born at 37 gestational weeks+ 0 days-42 weeks+ 6 days from the Theirworld Edinburgh Birth Cohort (n = 86) and Developing Human Connectome Project (n = 287). Skeletonized fractional anisotropy (FA), mean, axial and radial diffusivity (MD, AD, RD) maps were harmonized. Differences between voxel-wise metrics, skeleton means and histogram widths (5th-95th percentile) were assessed before and after harmonization, as well as variance associated with gestational age at birth and scan. Before harmonization, large cohort differences were observed. Harmonization removed all voxel-wise differences from MD maps and all metric means and histogram widths, however small voxel-wise differences (<1.5 % of voxels) remained in FA, AD and RD. We detected significant relationships between GA at birth and all metrics. When comparing single site and multisite harmonized datasets of equal sample sizes, harmonized data resulted in smaller standardized regression coefficients. ComBat could enable unprecedented sample sizes in developmental neuroscience, offering new horizons for biomarker discovery and validation, understanding typical and atypical brain development, and assessing neuroprotective therapies.

Genetically Predicted Gut Microbiota Mediate the Association Between Fatty Acids and Intrahepatic Cholestasis of Pregnancy: A Mendelian Randomization Analysis

Fatty acids (FAs) and gut bacteria likely play vital roles in intrahepatic cholestasis of pregnancy (ICP). However, the causal connection between FAs, gut microbiota, and ICP has not yet been confirmed. To investigate the associations of FAs, gut bacteria, and ICP, a Mendelian randomization (MR) analysis with two samples was performed to identify the potential causal relationships between FAs and ICP. The potential mediating role of gut bacteria in FAs and ICP was analyzed by a two-step MR analysis. False discovery rate (FDR) correction was conducted to correct the bias of multiple tests. MR analysis revealed that higher omega-6 FAs/total FAs (odds ratio [OR] = 2.563, 95% confidence interval [CI] = 1.362-4.824, FDR p = 0.016), linoleic acids/total FAs (OR = 3.812, 95%CI = 1.966-7.388, FDR p = 0.001), and average number of methylene groups (OR = 1.968, 95%CI = 1.390-2.785, FDR p = 0.001) are potential risk factors for ICP. However, omega-3 FAs (OR = 0.587, 95%CI = 0.394-0.874, FDR p = 0.031) and the average number of double bonds in an FA chain (OR = 0.575, 95%CI = 0.435-0.759, FDR p = 0.001) could reduce the risk of ICP. The abundance of 25 gut bacteria showed significant causal effects on ICP, among which Dokdonella may play a crucial role in modulating the effects of FAs on ICP. Our research results suggest that the effects of FA on ICP likely vary according to their different types. Dokdonella abundance plays a significant role in mediating the causal interactions between FAs and ICP.

Brain development using a multicomponent intravenous lipid emulsion in preterm infants

BACKGROUND

Intravenous lipid emulsions are an essential component of nutritional support for very preterm infants. Many neonatal intensive care units have transitioned from traditional soybean oil-only to fish oil-containing multicomponent lipid emulsions, but the neurodevelopmental implications have not been well-explored. The primary aim of this study was to assess extrauterine third trimester brain growth in very preterm infants supported with soybean oil-only compared to fish-oil containing multicomponent lipid emulsions; white matter development and neurobehavioral regulation at term were also investigated.

METHODS

Human milk-fed very preterm infants (born less than or equal to 32 weeks' gestation) receiving either soybean oil-only (before 2019) or multicomponent (after 2019) lipid emulsions underwent quantitative brain MRI (volumetric growth and white matter development) and neurodevelopmental assessment (Neonatal Intensive Care Unit Network Neurobehavioral Scale) at term-equivalent age. Analyses were adjusted for age at birth and term assessments, as well as clinically significant covariates.

RESULTS

92 infants (61 soybean, 31 multicomponent) were included (mean [SD] birth gestational age: 27.3 [2.3] weeks). Soybean oil-only infants demonstrated smaller brainstem volumes (β [95% CI] = -0.5 [-0.8,-0.1], p = .007); additionally less mature white matter development (mean diffusivity [MD, mm2/second x10- 3] and fractional anisotropy [FA]) in the corpus callosum (MD genu: β = 0.10 [0.01, 0.20], p = .04; splenium: β = 0.14 [0.04, 0.24], p = .006), posterior limbs of internal capsule (MD right (R): β = 0.05 [0.02, 0.08], p = .004, left (L): β = 0.04 [0.01, 0.08], p = .01; FA R: β = -0.03 [-0.06, -0.00], p = .03), and brainstem (FA R: β = 0.07 [0.04, 0.10], p < .001, L: β = 0.05 [0.02, 0.09], p = .002); and lower quality of movement (β = -0.54 [-0.97, -0.11], p = .02) and higher state-related stress (β = 1.41 [0.14, 2.83], p = .04).

CONCLUSIONS

Very preterm infants supported with a fish-oil containing multicomponent compared to soybean oil-only lipid emulsion demonstrated improved regional brain growth, as well as evidence of enhanced white matter microstructural organization and neurobehavioral regulation, at term corrected age.

TRIAL REGISTRATION

Clinical trial number: Not applicable.

Brain 3T magnetic resonance imaging in neonates: features and incidental findings from a research cohort enriched for preterm birth

BACKGROUND AND OBJECTIVES

The survival rate and patterns of brain injury after very preterm birth are evolving with changes in clinical practices. Additionally, incidental findings can present legal, ethical and practical considerations. Here, we report MRI features and incidental findings from a large, contemporary research cohort of very preterm infants and term controls.

METHODS

288 infants had 3T MRI at term-equivalent age: 187 infants born <32 weeks without major parenchymal lesions, and 101 term-born controls. T1-weighted, T2-weighted and susceptibility-weighted imaging were used to classify white and grey matter injury according to a structured system, and incidental findings described.

RESULTS

Preterm infants: 34 (18%) had white matter injury and 4 (2%) had grey matter injury. 51 (27%) infants had evidence of intracranial haemorrhage and 34 (18%) had punctate white matter lesions (PWMLs). Incidental findings were detected in 12 (6%) preterm infants. Term infants: no term infants had white or grey matter injury. Incidental findings were detected in 35 (35%); these included intracranial haemorrhage in 22 (22%), periventricular pseudocysts in 5 (5%) and PWMLs in 4 (4%) infants. From the whole cohort, 10 (3%) infants required referral to specialist services.

CONCLUSIONS

One-fifth of very preterm infants without major parenchymal lesions have white or grey matter abnormalities at term-equivalent age. Incidental findings are seen in 6% of preterm and 35% of term infants. Overall, 3% of infants undergoing MRI for research require follow-up due to incidental findings. These data should help inform consent procedures for research and assist service planning for centres using 3T neonatal brain MRI for clinical purposes.

Platelet characteristics in extremely preterm infants after fatty acid supplementation: a randomized controlled trial

BACKGROUND

Two risk factors for severe retinopathy of prematurity (ROP) in extremely preterm infants are thrombocytopenia and low levels of arachidonic acid (AA) and docosahexaenoic acid (DHA). To date, these risk factors have not been linked.

METHOD

Infants born < 28 weeks gestational age (GA) from 2016 to 2019 were randomized to postnatal enteral AA/DHA supplementation or standard care (controls). Levels of AA and DHA, platelet counts ( < 100 × 109/L defined as thrombocytopenia) and platelet-related proteins in the infants' first four weeks of life were evaluated for their association with severe ROP.

RESULTS

The mean birthweight of 178 included infants was 806 ± 200 grams, and the mean GA was 25.6 ± 1.4 weeks. During the first four postnatal weeks, 20.2% of AA/DHA-supplemented infants had thrombocytopenia versus 27.7% of controls (p = 0.29). In infants with thrombocytopenia, fewer AA/DHA-supplemented infants developed severe ROP than non-supplemented controls, 29.4% (5/17) versus 65.4% (17/26) (p = 0.031). Thrombocytopenia and serum levels of AA and DHA correlated with several platelet-related proteins involved in angiogenesis and ROP, such as platelet-derived growth factor subunits A and B and vascular endothelial growth factor.

CONCLUSIONS

AA and DHA supplementation is associated with less severe ROP in thrombocytopenic infants, possibly by modulating platelet activation and function.

IMPACT

Postnatal enteral supplementation with arachidonic acid (AA) and docosahexaenoic acid (DHA) to extremely preterm infants reduces the risk of severe retinopathy of prematurity (ROP) in infants with thrombocytopenia. The impact of AA and DHA might be, at least in part, mediated through altered platelet activation. We found that AA and DHA may reduce the risk of severe ROP, possibly by modulating platelet-related proteins involved in angiogenesis. Our findings strongly support that supplementing AA and DHA to extremely preterm infants is crucial and can significantly impact their health.

Maternal high-dose docosahexaenoic acid supplementation and neurodevelopment at 5 Years of preterm children

BACKGROUND & AIMS

Docosahexaenoic acid (DHA) is the most abundant omega-3 fatty acid in the brain and is accumulated by the fetal brain during the last trimester of pregnancy. Our objective was to determine whether high-dose DHA supplementation during the neonatal period, vs. placebo, improves behavioral functioning at 5 years in children born very preterm.

METHODS

This is a follow-up at 5 years corrected age of a subset of children who participated in a multicenter randomized controlled trial. The participants received a high-dose DHA supplementation, or a placebo, through maternal breastmilk until 36 weeks' postmenstrual age. Primary outcome was child behavioral functioning, assessed by the Total Difficulties Score from the Strengths and Difficulties Questionnaire (SDQ). Secondary outcomes included behavioral scores from the SDQ, executive functions assessment and global developmental performance. Neurodevelopmental outcomes were assessed through interviews with parents. Mean differences between DHA and placebo groups were estimated using mixed linear models. Subgroup analyses were conducted for sex and gestational age (GA) at birth.

RESULTS

Among 177 eligible children, 132 (74.6 %) completed neurodevelopmental assessment at 5 years (DHA, N = 64, placebo, N = 68). Total Difficulties Score did not differ between the DHA and placebo groups (mean differences, -0.9 [95 % confidence interval, -2.7 to 0.8], P = 0.30), nor any of the secondary outcomes. There was no significant interaction between treatment groups and sex, nor GA, for the primary outcome. However, significant interactions between treatment groups and sex or GA were found for some secondary outcomes.

CONCLUSIONS

In very preterm infants, high-dose DHA supplementation did not improve behavioral functioning at 5 years.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT02371460, https://clinicaltrials.gov/study/NCT02371460.

Toward Supplementation Guidelines for Vegan Complementary Feeding

Previously published recommendations for vegetarian (including vegan) diets for children have highlighted the need for vitamin B12 supplementation. Increased attention to several other key nutrients (including iodine, vitamin D, calcium, and iron) has also been recommended. However, an overview focusing on supplementation guidelines, specifically for vegan infants, has not been published, and a potential requirement for iodine and/or selenium supplementation in (some) vegan infants has not been discussed. Vegan complementary feeding should be supplemented (particularly with 5 μg/day of vitamin B12 and 10 μg/day of vitamin D). Iodine should be supplemented (up to 110 μg/day) if the intake of breast milk and infant formula is low, and selenium supplementation (5 μg/day) should be considered in regions with low soil selenium levels. Caution is required to avoid excessive intakes of iodine and particularly selenium. Supplements for vegan infants are on the market, and observational studies are urgently needed to assess the nutrient intake (including supplements) and status in vegan infants.

A Narrative Review of Strategies to Optimize Nutrition, Feeding, and Growth among Preterm-Born Infants: Implications for Practice

Preterm birth is the leading cause of neonatal and under-5 mortality globally, and healthcare-related burden and nutrition-related morbidities are unsustainable, particularly in resource-limited regions. Additionally, preterm infants are susceptible to multiple adverse outcomes including growth faltering, suboptimal neurodevelopment, and multisystemic morbidities. Maturation, healing, repair, and restoration to normalcy in preterm-born infants require optimizing nutrition; only then, prognosis, growth, neurodevelopment, and overall quality of life can improve. In this article, we discuss the various evidence-based feeding and nutritional strategies that can be applicable even in resource-limited settings, where resources and infrastructure for advanced neonatal care are limited. This article addresses nutrition, feeding strategies, and growth monitoring in the neonatal intensive care unit and at discharge to optimize nutrition, growth, and development.

Docosahexaenoic acid supplementation and infant brain development: role of gut microbiome

Perinatal stage represents a critical period for brain development. Docosahexaenoic acid (DHA) is a ω-3 polyunsaturated fatty acid preferentially accumulated in the brain that may benefit neurodevelopment. Microbial colonization and maturation parallel with the rapid development of infant metabolic and brain function that may influence the effects of DHA on neurological development. This review aims to summarize the current literature on the mediating effects of DHA on brain and gut microbiome development and attempts to reevaluate the efficacy of DHA from a gut microbiome-mediated perspective. Specifically, the regulatory roles of DHA on hypothalamic-pituitary-adrenal axis, inflammation, and neuroactive mediators may be partly moderated through gut microbiome. Consideration of the gut microbiome and gut-brain communication, when evaluating the efficacy of DHA, may provide new insights in better understanding the mechanisms of DHA and impart advantages to future development of nutritional therapy based on the nutrient-microbiome interaction.

Macronutrient Intake during Complementary Feeding in Very Low Birth Weight Infants Comparing Early and Late Introduction of Solid Foods: A Secondary Outcome Analysis

Background/Objectives: Very low birth weight (VLBW) infants may require enhanced nutrition, even during complementary feeding. However, there are limited data on macronutrient intake during this period, particularly concerning the individual timing of the introduction of solid foods in a representative VLBW infant population. Methods: This prospective observational study analyzed macronutrient intake in VLBW infants with a gestational age < 32 weeks based on whether solid foods were introduced early (<17 weeks corrected age (CA)) or late (≥17 weeks corrected age) Nutritional intake was analyzed using a 24 h recall at 6 weeks CA and 3-day dietary records at 12 weeks, 6, 9, and 12 months CA. Results: In total, 115 infants were assigned to the early and 82 to the late group. The timing of solid food introduction did not affect macronutrient intake, except for a lower fat and higher carbohydrate intake (% of energy) in the early group at 12 weeks and 6 months CA: early vs. late, fat-12 weeks: 47.0% vs. 49.0%, 6 months: 39.2% vs. 43.3%; carbohydrates-12 weeks: 44.9% vs. 43.2%, 6 months: 51.3% vs. 48.0%. Apart from docosahexaenoic acid (DHA) and arachidonic acid (AA), dietary intake recommendations were met in both groups. While nutrient intakes varied significantly between breastfed and formula-fed infants, those with comorbidities exhibited similar nutrient intake levels compared to those without. Conclusions: Our findings suggest adequate macronutrient intakes in VLBW infants irrespective of the timing of solid introduction. However, there is a notable need to enhance dietary intakes of DHA and AA. Future research is crucial to assess whether current nutrient intakes are sufficient for VLBW infants with comorbidities.

Dietary Supplementation with n-3 Polyunsaturated Fatty Acids Delays the Phenotypic Manifestation of Krabbe Disease and Partially Restores Lipid Mediator Production in the Brain-Study in a Mouse Model of the Disease

Lipid mediators from fatty acid oxidation have been shown to be associated with the severity of Krabbe disease (KD), a disorder linked to mutations in the galactosylceramidase (GALC) gene. This study aims to investigate the effects of n-3 polyunsaturated fatty acid (PUFA) supplementation on KD traits and fatty acid metabolism using Twitcher (Tw) animals as a natural model for KD. Wild-type (Wt), heterozygous (Ht), and affected Tw animals were treated orally with 36 mg n-3 PUFAs/kg body weight/day from 10 to 35 days of life. The end product of PUFA peroxidation (8-isoprostane), the lipid mediator involved in the resolution of inflammatory exudates (resolvin D1), and the total amount of n-3 PUFAs were analyzed in the brains of mice. In Tw mice, supplementation with n-3 PUFAs delayed the manifestation of disease symptoms (p < 0.0001), and in the bran, decreased 8-isoprostane amounts (p < 0.0001), increased resolvin D1 levels (p < 0.005) and increased quantity of total n-3 PUFAs (p < 0.05). Furthermore, total brain n-3 PUFA levels were associated with disease severity (r = -0.562, p = 0.0001), resolvin D1 (r = 0.712, p < 0.0001), and 8-isoprostane brain levels (r = -0.690, p < 0.0001). For the first time in a natural model of KD, brain levels of n-3 PUFAs are shown to determine disease severity and to be involved in the peroxidation of brain PUFAs as well as in the production of pro-resolving lipid mediators. It is also shown that dietary supplementation with n-3 PUFAs leads to a slowing of the phenotypic presentation of the disease and restoration of lipid mediator production.

Evidence on docosahexaenoic acid and arachidonic acid supplementation for preterm infants

PURPOSE OF REVIEW

For many decades, docosahexaenoic acid (DHA) supplementation was tested in premature infants to achieve an intake equivalent to the average level in breast milk, but this approach has led to conflicting results in terms of development and health outcomes. Higher doses of DHA closer to fetal accumulation may be needed.

RECENT FINDINGS

The efficacy of DHA supplementation for preterm infants at a dose equivalent to the estimated fetal accumulation rate is still under investigation, but this may be a promising approach, especially in conjunction with arachidonic acid supplementation. Current data suggest benefit for some outcomes, such as brain maturation, long-term cognitive function, and the prevention of retinopathy of prematurity. The possibility that supplementation with highly unsaturated oils increases the risk of neonatal morbidities should not be ruled out, but current meta-analyzes do not support a significant risk.

SUMMARY

The published literature supports a DHA intake in preterm infants that is closer to the fetal accumulation rate than the average breast milk content. Supplementation with DHA at this level in combination with arachidonic acid is currently being investigated and appears promising.