Nutrient deficiencies in the premature infant

Nutrition and Growth of Preterm Neonates during Hospitalization: Impact on Childhood Outcomes

The Special Issue has been completed with the publication of 13 review and research articles [...].

Measuring growth in critically ill neonates and children

Critical illness increases the risk of malnutrition in both infants and children. Malnutrition risk is multifactorial and includes premorbid factors as well as changes in nutrient metabolism and energy demands during critical illness. Inadequate nutrition has been linked to poor health outcomes and prolonged length of stay in the intensive care unit, demonstrating the importance of both recognizing and addressing malnutrition in this population. Assessing growth and identifying malnutrition requires methodical measurement of growth and a collaborative, multimodal approach to nutrition assessment. Among the nutrition assessment and growth evaluation tools, neonatal, preterm, pediatric, and disease-specific growth charts remain an important component of growth assessment and should be used along with a nutrition-focused physical examination. Routine measurement promotes the identification of potential growth delays that may require interventions. Indirect calorimetry adds an additional layer of detail for a complete picture of each infant or child's unique nutrition status and progress. Quality improvement research on a national level is urgently needed to assess the adequacy and availability of resources in neonatal and pediatric critical care units and to further the development of standard clinical outcome measures for nutrition assessment and intervention in the critically ill neonate and child.

Classification and Special Nutritional Needs of SGA Infants and Neonates of Multiple Pregnancies

Data regarding the nutritional management of preterm small for gestational age (SGA) infants are scarce. In the recent report of ESPGHAN, the recommended energy for very preterm infants during hospitalization has been increased, yet this may not fit the needs of all preterm infants. It is important to distinguish fetal growth-restricted (FGR) infants from constitutional SGA infants, as well as preterm SGA from preterm AGA infants, since they may have different nutritional needs. Preterm FGR infants, and specifically infants < 29 weeks' gestation, accumulate nutrient deficits due to intrauterine malnutrition, prematurity, morbidities, delayed initiation of feeding, and feeding intolerance. Therefore, these infants may need more aggressive nutrition for optimal catch-up growth and neurologic development. However, a balance should be kept between optimal and excessive catch-up growth, since the combination of intrauterine malnutrition and excessive postnatal growth has been linked with later adverse metabolic consequences. Furthermore, multiple gestation is often complicated by FGR and prematurity. There is controversy in the definition of FGR in multiple gestations, and it should be noted that FGR in multiple gestation usually differs etiologically from FGR in singletons. The aim of this review is to summarize existing knowledge regarding the nutritional needs of preterm FGR and FGR infants of multiple gestation.

Misdiagnosis of Total Parental Nutrition-Related Riboflavin Deficiency: Three Case Reports of Diagnostic Error

Total parental nutrition (TPN) is a critical component of neonatal intensive care. Supply shortages leading to deficiencies in TPN constituents can have devastating consequences for critically ill patients in the neonatal intensive care unit (NICU), who may be initially misdiagnosed as potential inborn errors of metabolism. Here, we present three cases of patients with prolonged TPN dependence due to intra-abdominal pathology who presented with signs and symptoms concerning for metabolic disorders and who were ultimately determined to be a result of vitamin deficiencies in the TPN after unnecessary testing and interventions had occurred. These diagnostic errors highlight the need for clinicians to maintain a high index of suspicion for nutritional deficiencies when treating patients in the NICU with potential metabolic disorders during times when TPN constituents are not available, as well as advocating to ensure that adequate supplies are maintained for this vulnerable population.

Iron Status of the Moderate and Late Preterm Infant: A Prospective Cohort Study

Guidelines on micronutrient supplementation in moderate to late preterm infants (MLP) are mostly extrapolated from those for smaller preterms, largely due to lack of systematic studies on physiological status in this special group of infants. Actual practices vary widely. We prospectively studied iron status by measurement of serum ferritin (SF) and haematological indices at 4 months corrected age in infants born between 32 and 36 weeks gestation (MLP), after they received 2 mg/kg/day oral iron from 6 weeks of postnatal age. Proportion of MLP having normal iron status (iron replete), i.e., neither iron deficiency (ID) nor iron excess was measured. ID anaemia, growth and development, risk factors for ID were also analysed. Of the 82 infants studied, 78% babies were late preterm. Seventy-four (90.3%) were iron replete (no deficiency or excess) at 4 months. High variability in SF levels (minimum of 9.8 to maximum of 252.2 μg/l) with median (IQR) of 57.45 μg/l (37.02-98.85) was noted in the entire cohort; and also within those who were iron deficient with median (IQR) of 17.50 μg/l (11.70-18.90). There was no difference in haematological indices of ID infants when compared to those with normal iron status. Inspite of oral iron supplementation with reasonable compliance, 8.5% MLP were iron deficient at 4 months corrected age. The high variability noted in SF levels could justify the need for monitoring iron status in this group of preterm infants. This could quintessentially aid individualization of iron supplementation advice.

Effects of Total Enteral Nutrition on Early Growth, Immunity, and Neuronal Development of Preterm Infants

The feeding of colostrum and mother's transitional milk improves immune protection and neurodevelopmental outcomes. It also helps with gut maturation and decreases the risks of infection. The supply of nutrients from human milk (HM) is not adequate for preterm infants, even though preterm mother's milk contains higher concentrations of protein, sodium, zinc, and calcium than mature HM. The human milk fortifiers, particularly those with protein, calcium, and phosphate, should be used to supplement HM to meet the necessities of preterm infants. The management of fluid and electrolytes is a challenging aspect of neonatal care of preterm infants. Trace minerals such as iron, zinc, copper, iodine, manganese, molybdenum, selenium, chromium, and fluoride are considered essential for preterm infants. Vitamins such as A, D, E, and K play an important role in the prevention of morbidities, such as bronchopulmonary dysplasia, retinopathy of prematurity, and intraventricular hemorrhage. Therefore, supplementation of HM with required nutrients is recommended for all preterm infants.

Concentrations of fat-soluble nutrients and blood inflammatory compounds in mother-infant dyads at birth

BACKGROUND

Perinatal inflammation adversely affects health. Therefore, aims of this IRB-approved study are: (1) compare inflammatory compounds within and between maternal and umbilical cord blood samples at the time of delivery, (2) assess relationships between inflammatory compounds in maternal and cord blood with birth characteristics/outcomes, and (3) assess relationships between blood and placental fat-soluble nutrients with blood levels of individual inflammatory compounds.

METHODS

Mother-infant dyads were enrolled (n = 152) for collection of birth data and biological samples of maternal blood, umbilical cord blood, and placental tissue. Nutrient levels included: lutein + zeaxanthin; lycopene; α-, β-carotene; β-cryptoxanthin; retinol; α-, γ-, δ-tocopherol. Inflammatory compounds included: tumor necrosis factor-α, superoxide dismutase, interleukins (IL) 1β, 2, 6, 8, 10.

RESULTS

Median inflammatory compound levels were 1.2-2.3 times higher in cord vs. maternal blood, except IL2 (1.3 times lower). Multiple significant correlations existed between maternal vs. infant inflammatory compounds (range of r = 0.22-0.48). While relationships existed with blood nutrient levels, the most significant were identified in placenta where all nutrients (except δ-tocopherol) exhibited relationships with inflammatory compounds. Relationships between anti-inflammatory nutrients and proinflammatory compounds were primarily inverse.

CONCLUSION

Inflammation is strongly correlated between mother-infant dyads. Fat-soluble nutrients have relationships with inflammatory compounds, suggesting nutrition is a modifiable factor.

IMPACT

Mother and newborn inflammation status are strongly interrelated. Levels of fat-soluble nutrients in blood, but especially placenta, are associated with blood levels of proinflammatory and anti-inflammatory compounds in both mother and newborn infant. As fat-soluble nutrient levels are associated with blood inflammatory compounds, nutrition is a modifiable factor to modulate inflammation and improve perinatal outcomes.

Branched-chain amino acid supplementation for improving growth and development in term and preterm neonates

BACKGROUND

Branched-chain amino acids (BCAAs) play a vital role in neonatal nutrition. Optimal BCAA supplementation might improve neonatal nutrient storage, leading to better physical and neurological development and other outcomes.

OBJECTIVES

To determine the effect of BCAA supplementation on physical growth and neurological development in term and preterm neonates. We planned to make the following comparisons: parenteral nutrition with and without BCAA supplementation; enteral BCAA supplementation versus no supplementation; and any type of supplementation including enteral, parenteral and both ways versus no supplementation. To investigate the supplementation effectiveness for different dosages assessed in the eligible trials.

SEARCH METHODS

We conducted comprehensive searches using Cochrane Neonatal's standard search strategies: Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 6), MEDLINE, Embase and CINAHL (up to July 2016). We updated the search with CENTRAL (2019, Issue 8), MEDLINE, Embase and CINAHL (up to August 2019). We also searched clinical trials registries and reference lists of retrieved articles.

SELECTION CRITERIA

We planned to include individual and cluster-randomised and quasi-randomised controlled trials comparing BCAA supplementation versus placebo or no supplementation in term and preterm neonates. We excluded trials presented only as abstracts and cross-over trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of all potential studies identified from the search strategy. We planned to extract data using a pilot-tested standard data extraction form and assess risk of bias of the included studies following the methods described in the Cochrane Handbook for Systematic Reviews of Interventions. We planned to analyse treatment effects and report their effect estimates as per dichotomous or continuous data with 95% confidence intervals. We planned to conduct subgroup analysis to investigate heterogeneity, and perform sensitivity analysis where possible. We planned to use fixed-effect meta-analysis to combine data wherever appropriate. We planned to assess evidence quality using the GRADE approach.

MAIN RESULTS

We did not identify any potentially eligible studies that met the inclusion criteria in this review.

AUTHORS' CONCLUSIONS

We found no trial data to support or refute the idea that BCAA supplementation affects physical and neurological development and other outcomes in term and preterm neonates.

Antioxidant Capacity of Preterm Neonates Assessed by Hydrogen Donor Value

Background and objectives: Premature newborns have a number of oxidative stress-inducing disorders. Antioxidant defense is deficient in premature newborns. Hydrogen donors can be used to evaluate the non-enzymatic antioxidant defense. By measuring hydrogen donors, a group of antioxidants can be assessed: tocopherol, ascorbic acid, and glutathione. These represent the most relevant group of non-enzymatic antioxidants. The main aim of this study was to evaluate the non-enzymatic antioxidant defense capacity of premature newborns by measuring hydrogen donors. Materials and Methods: We evaluated the non-enzymatic antioxidant capacity by hydrogen donor measurement in 24 premature newborns with various oxidative stress-inducing disorders and in 14 premature newborns without oxidative stress-inducing conditions. Statistical analysis was performed using the Statistica program (v. 8, StatSoft, Round Rock, TX, USA). Differences between groups were tested with Wilcoxon matched test for quantitative paired data or Mann-Whitney test for quantitative independent data. The Z test for proportions was used to compare qualitative data among subgroups. Results: Hydrogen donors in the study group had a significantly lower value on the first day of life compared to the value of the control group. Also, the hydrogen donor value in the study group was significantly lower on the first day compared to the third day of life (p < 0.05). Neonates with mild respiratory distress (14 cases) had increased hydrogen donor values on their third day of life compared to the first day of life. Conclusions: The antioxidant capacity is influenced by oxidative stress-inducing disorders. Respiratory distress influenced the hydrogen donor value and antioxidant defense. Antioxidant defense gradually improves after birth according to gestational age.

Current practice in the introduction of solid foods for preterm infants

OBJECTIVE

The present study compared the age of first solid foods in a cohort of preterm infants with term infants and identified factors influencing timing of solid food introduction.

DESIGN

Structured interviews on infant feeding practices, growth and medical status at term equivalence and at 3, 6, 9 and 12 months corrected postnatal age. The age of solid food introduction was compared between term and preterm infants, and the influence of maternal, infant and milk feeding factors was assessed.

SETTING

This prospective longitudinal study recruited primary carers of preterm and term infants from a regional metropolitan referral hospital in eastern Australia.

PARTICIPANTS

One hundred and fifty infants (preterm, n 85; term, n 65).

RESULTS

When corrected for prematurity, preterm infants received solid foods before the recommended age for the introduction of solid foods for term infants. Median introduction of solid foods for preterm infants was 14 weeks corrected age (range 12-17 weeks). This was significantly less than 19 weeks (range 17-21 weeks) for term infants (P < 0·001). Lower maternal education and male gender were associated with earlier introduction of solid foods among preterm infants.

CONCLUSIONS

Preterm infants are introduced to solid foods earlier than recommended for term infants, taking account of their corrected age. Further research is needed to assess any risk or benefit associated with this pattern and thus to develop clear evidence-based feeding guidelines for preterm infants.

Dietary patterns before and during pregnancy and birth outcomes: a systematic review

BACKGROUND

Maternal diet before and during pregnancy could influence fetal growth and birth outcomes.

OBJECTIVE

Two systematic reviews aimed to assess the relationships between dietary patterns before and during pregnancy and 1) gestational age at birth and 2) gestational age- and sex-specific birth weight.

METHODS

Literature was searched from January, 1980 to January, 2017 in 9 databases including PubMed, Embase, and Cochrane. Two analysts independently screened articles using predetermined inclusion and exclusion criteria. Data were extracted from included articles and risk of bias was assessed. Data were synthesized qualitatively, a conclusion statement was drafted for each question, and evidence supporting each conclusion was graded.

RESULTS

Of the 9103 studies identified, 11 [representing 7 cohorts and 1 randomized controlled trial (RCT)] were included for gestational age and 21 (representing 19 cohorts and 2 RCTs) were included for birth weight. Limited but consistent evidence suggests that certain dietary patterns during pregnancy are associated with a lower risk of preterm birth and spontaneous preterm birth. These protective dietary patterns are higher in vegetables; fruits; whole grains; nuts, legumes, and seeds; and seafood (preterm birth, only), and lower in red and processed meats, and fried foods. Most of the research was conducted in healthy Caucasian women with access to health care. No conclusion can be drawn on the association between dietary patterns during pregnancy and birth weight outcomes. Although research is available, the ability to draw a conclusion is restricted by inconsistency in study findings, inadequate adjustment of birth weight for gestational age and sex, and variation in study design, dietary assessment methodology, and adjustment for key confounding factors. Insufficient evidence exists regarding dietary patterns before pregnancy for both outcomes.

CONCLUSIONS

Maternal dietary patterns may be associated with a lower preterm and spontaneous preterm birth risk. The association is unclear for birth weight outcomes.

Prevalence of Anemia and Its Associated Risk Factors Among 6-Months-Old Infants in Beijing

Objective: The worldwide prevalence of anemia is ~24.8%. Iron deficiency anemia is common in children and women and associated with sensory, motor, cognitive, language, and socioemotional deficits. Therefore, detection and early intervention strategies for anemia in infants are urgently needed. To prevent the occurrence of iron deficiency anemia, we aimed to identify risk factors associated with anemia in infants. Methods: This investigation involved a cross-sectional study of 6-months-old infants discharged between April 2014 and September 2017 from Peking University First Hospital. We assessed birth information, maternal age, and maternal educational level as well as data on feeding style, complementary foods and primary caregivers. The infants were assessed with the Denver Developmental Screening Test (DDST). Results: A total of 1,127 6-months-old infants were enrolled at the hospital. We found that the prevalence of anemia among infants in Beijing was ~11.8%. Premature infants had a higher rate of anemia than full-term infants (χ² = 40.103, P < 0.001). Infants born in autumn or winter were at an elevated risk of developing anemia (χ² = 22.949, P < 0.001). Birth weight had no effect on the rate of anemia in infants (χ² = 0.023, P = 0.568). Infants who were exclusively breastfeeding had higher anemia rates than those who were fed formula (χ² = 38.466, P < 0.001). Infants whose caregivers added no complementary foods had higher anemia rates (24.7%) than those whose caregivers added more than two kinds of complementary food (8.2%). The type of caregiver had no effect on the anemia rate in infants (χ² = 0.031, P = 1.000). Conclusions: The following factors resulted in a higher prevalence of anemia in our study a gestational age at birth of <37 weeks, exclusive breastfeeding, a lack of supplementation with complementary foods and a spring birth date. No significant differences in DDST pass rates were evident between infants with and without anemia.

Tolerance of Hydrolyzed Liquid Protein Fortified Human Milk and Effect on Growth in Premature Infants

BACKGROUND

We evaluated tolerance of hydrolyzed liquid protein (LP) supplement added to fortified human milk (HM) to optimize protein intake in preterm infants.

METHODS

A prospective observational study of 31 subjects compared with 31 historic controls, receiving mothers own milk (MOM) and/or donor milk (DM) to assess LP tolerance, growth, and risk for morbidities was conducted. Milk was analyzed for nutrient content. Feeding intolerance, defined as cessation of feedings for ≥48 hours, abdominal distension and/or residuals, necrotizing enterocolitis (NEC), and metabolic acidosis were used to assess safety, while weight and head circumference (HC) were used to evaluate growth.

RESULTS

LP added to powder-fortified HM had no impact on feeding intolerance and NEC. Biochemical parameters showed no metabolic acidosis: blood urea nitrogen levels (first week: median, 13 mg/dL; interquartile range [IQR], 9-16; last week: median, 13 mg/dL; IQR, 10.3-14; P = .94), bicarbonate levels (first week: median, 26.3 mEq/L; IQR, 24-28; last week: median, 28 mEq/L; IQR, 26.3-29.8; P = .10), and pH levels (first week: median, 7.4; IQR, 7.3-7.4; last week: median, 7.4; IQR, 7.37-7.40; P = .5). Weight and HC were not statistically significant. HM analysis showed lower protein and caloric content, respectively (MOM: 0.88 vs DM: 0.77 g/100 mL; P < .0001 and MOM: 18.68 vs DM: 17.96 kcal/oz; P = .02).

CONCLUSIONS

Hydrolyzed LP is well tolerated in preterm infants with no difference in growth rates. Clinicians should focus on the need to maximize both protein and energy to optimize growth.

Selenium fortification of infant formulas: does selenium form matter?

Selenium is a trace element essential for the health and development of the growing infant. It is a necessary component of proteins and enzymes required for a variety of functions, including antioxidant defense, modulation of the inflammatory response, and production of thyroid hormones. In breast-fed infants, selenium stores depend on the selenium content of the mother's diet. In formula-fed infants, selenium levels are correlated to the residual selenium stores accumulated in utero and the level and type of selenium fortification used in the formula. Today, the United States Food and Drug Administration (FDA) recommends that infant formulas contain selenium at levels between 2.0 and 7.0 μg per 100 kcal. While the US FDA does not recommend a particular selenium form for fortification, evidence indicates that organically bound selenium forms (e.g., selenomethionine and selenium-enriched yeast) are better absorbed and retained than inorganic forms (e.g., selenite and selenate). Preliminary data from studies in adults do suggest that fortification with standardized selenium-enriched yeast may offer benefits compared to fortification with other organically bound selenium forms. However, because most studies evaluating the impact of selenium fortification of infant formula have assessed inorganic selenium supplements, additional research into the bioavailability and outcomes associated with the use of selenium-enriched yeast in infants is needed.

Serum 25 Hydroxy Vitamin D Levels in Very Low Birth Weight Infants Receiving Oral Vitamin D Supplementation

BACKGROUND AND OBJECTIVE

Vitamin D supplementation in preterm infants has been recommended by American Academy of Pediatrics (AAP); however, its efficacy and safety has not been well studied. To study 25-hydroxy vitamin D (25OHD) levels as a marker of vitamin D status of very low birth weight infants while on vitamin D supplementation during neonatal intensive care unit hospitalization.

METHODS

Retrospective study of preterm infants with birth weight <1500 g admitted to our unit from January 2013 to December 2015 who were on oral vitamin D3 400 IU supplementation. Serum 25OHD level were checked at 4, 8, and 12 weeks of age or before discharge and the levels were stratified as deficient <20 ng/mL, insufficient 20 to 29 ng/mL, normal 30 to 60 ng/mL, high 61 to 100 ng/mL and very high >100 ng/mL.

RESULTS

A total of 301 infants were enrolled, 186 very low birth weight (VLBW; 1000-1499 g) infants and 115 extremely low birth weight (ELBW; <1000 g) infants. Approximately 80% of both VLBWs and ELBWs had deficient or insufficient 25OHD levels at 4 weeks of age. On oral vitamin D supplementation, VLBW infants increased their 25OHD levels significantly by 8 and 12 weeks of age, whereas ELBW infants lagged behind at 8 weeks and increased their 25OHD levels by 12 weeks of age.

CONCLUSIONS

Eighty percent of ELBW and VLBW infants have either deficient or insufficient vitamin D status at 4 weeks of age. Vitamin D supplementation helps in improving the vitamin D levels, VLBW infants significantly more than ELBW infants. AAP recommendation appears to be safe; however, if using higher supplement dosing, 25OHD level should be monitored to avoid high and very high vitamin D levels.

Modulatory Mechanism of Polyphenols and Nrf2 Signaling Pathway in LPS Challenged Pregnancy Disorders

Early embryonic loss and adverse birth outcomes are the major reproductive disorders that affect both human and animals. The LPS induces inflammation by interacting with robust cellular mechanism which was considered as a plethora of numerous reproductive disorders such as fetal resorption, preterm birth, teratogenicity, intrauterine growth restriction, abortion, neural tube defects, fetal demise, and skeletal development retardation. LPS-triggered overproduction of free radicals leads to oxidative stress which mediates inflammation via stimulation of NF-κB and PPARγ transcription factors. Flavonoids, which exist in copious amounts in nature, possess a wide array of functions; their supplementation during pregnancy activates Nrf2 signaling pathway which encounters pregnancy disorders. It was further presumed that the development of strong antioxidant uterine environment during gestation can alleviate diseases which appear at adult stages. The purpose of this review is to focus on modulatory properties of flavonoids on oxidative stress-mediated pregnancy insult and abnormal outcomes and role of Nrf2 activation in pregnancy disorders. These findings would be helpful for providing new insights in ameliorating oxidative stress-induced pregnancy disorders.

Neonatal and Maternal 25-OH Vitamin D Serum Levels in Neonates with Early-Onset Sepsis

Vitamin D is a fat-soluble vitamin that is important for calcium metabolism and plays an important role in the immune functions. The aim of this study was to measure neonatal and maternal 25-OH vitamin D serum levels in neonates with early onset sepsis. The study included fifty neonates with early onset sepsis (25 full-term and 25 preterm infants) and thirty age and sex matched healthy neonates as controls. After history taking and clinical examination, complete blood count, C-reactive protein and 25-OH vitamin D serum levels (neonatal and maternal) were measured for all neonates. The mean gestational age for neonates with sepsis was (37.5 ± 0.98 for full term and 34.1 ± 1.26 for preterm neonates). Neonatal and maternal 25-OH vitamin D serum levels were significantly lower in patients (6.4 ± 1.8 and 24.6 ± 2.2 nmol/L) than controls (42.5 ± 20.7 and 50.4 ± 21.4 nmol/L). Significant negative correlations between neonatal and maternal 25-OH vitamin D serum levels and all sepsis markers and significant positive correlations between neonatal and maternal 25-OH vitamin D levels were present. At cut-off values <20 nmol/L for neonatal and <42 nmol/L for maternal 25-OH vitamin D for detection of neonatal sepsis, the sensitivity, specificity, positive predicted value (PPV) and negative predicted value (NPV) were 84%, 79%, 94.7% and 82.3% for neonatal and 82%, 77%, 91.4% and 80.6% for maternal 25-OH vitamin D, respectively. Positive correlations between neonatal and maternal 25-OH Vitamin D serum levels are present and they are negatively correlated with all sepsis markers. They can be sensitive early predictors for early onset sepsis in neonates.

Simultaneous determination of eight B-vitamins in rat intestinal perfusate to identify effects of osmotic pressures on absorptions

A rapid and accurate HPLC-DAD method was developed and validated to simultaneously determine eight B-vitamins (VBs, namely thiamine, riboflavin, niacinamide, calcium pantothenic, pyridoxine, biotin, folic acid and cyanocobalamin) and phenolsulfonphthalein in rat intestinal perfusate. Chromatographic separation was achieved using an Inertsil ODS-3 column (250 × 4.6 mm i.d., 5 μm) at a temperature of 40°C. Gradient elution mode was applied at the flow rate of 1.0 mL/min with the mobile phase of acetonitrile-30 mm K₂ HPO₄ (pH 5.80). The method was successfully applied to identify the effects of osmotic pressures on the absorption of the VBs. The absorption profiles of single and mixed VBs were also compared. Histological section technology was applied to observe the microstructure of small bowel mucosa after perfusion. The results indicated that each compound possessed a better absorption profile under isotonic conditions than under hypotonic or hypertonic conditions for single or mixed solutions. Compared with single VBs, better absorptions in mixed VBs were observed. Pathological tissue slice test suggested that hypotonic and hypertonic solutions changed or damaged the microstructure of mucosa to varying degrees. Taken together, the investigations indicated that multi-VBs administered orally under isotonic condition could generate fast and complete absorption profiles for VBs.

Vitamin D and bronchopulmonary dysplasia in preterm infants

OBJECTIVE

Vitamin D deficiency is associated with asthma and reactive airway disease in childhood but its potential contribution to bronchopulmonary dysplasia (BPD) in preterm infants is unknown. Preterm infants have lower levels of 25-hydroxyvitamin D (25(OH)D) at birth and are at risk for nutritional deficiencies after birth. The objective of the study was to evaluate the association of 25(OH)D concentrations at birth and at 36 weeks' corrected gestational age with BPD in preterm infants born before 29 completed weeks of gestation.

STUDY DESIGN

We collected umbilical cord blood samples from 44 preterm infants (gestational age <29 weeks) delivered at Brigham and Women's Hospital in Boston. In addition, with parental consent we collected venous samples at 36 weeks' corrected age from 20 preterm infants born before 29 weeks' gestation (including 6 infants with previously collected cord blood). Samples were frozen at -80 °C until subsequent measurement of 25(OH)D levels by chemiluminescence. We used multivariable logistic models to adjust for gestational age and considered other confounding variables, including maternal race, age, mode of delivery and infant sex.

RESULTS

Among 44 infants, 41 (93.2%) survived and 3 (6.8%) died before 36 weeks' corrected age. Median 25(OH)D levels at birth were 30.4 ng ml(-1) in preterm infants who subsequently died or developed BPD and 33.8 ng ml(-1) in infants who survived without BPD (P=0.6). Median 25(OH)D levels at corrected age of 36 weeks were 59.0 ng ml(-1) among survivors without BPD and 64.2 ng ml(-1) among survivors with BPD (P=0.9). Neither cord blood nor 36 weeks' corrected 25(OH)D levels were associated with odds of death or BPD (adjusted odds ratio (OR) 1.00, 95% confidence interval (CI): 0.73 to 1.37; and OR 0.93, 95% CI: 0.61 to 1.43, respectively).

CONCLUSIONS

Among this population of extremely preterm infants neither cord blood nor the 36 weeks' corrected age 25(OH)D levels were associated with development of BPD. Notably, at the current level of supplementation, all extremely preterm infants in our cohort had achieved 25(OH)D levels >30 ng ml(-1) by 36 weeks' corrected age, which is thought to represent sufficiency in adult and pediatric populations.

Micronutrient supplementation adherence and influence on the prevalences of anemia and iron, zinc and vitamin A deficiencies in preemies with a corrected age of six months

OBJECTIVE

To analyze adherence to the recommended iron, zinc and multivitamin supplementation guidelines for preemies, the factors associated with this adherence, and the influence of adherence on the occurrence of anemia and iron, zinc and vitamin A deficiencies.

METHODS

This prospective cohort study followed 58 preemies born in 2014 until they reached six months corrected age. The preemies were followed at a referral secondary health service and represented 63.7% of the preterm infants born that year. Outcomes of interest included high or low adherence to iron, zinc and multivitamin supplementation guidelines; prevalence of anemia; and prevalences of iron, zinc, and vitamin A deficiencies. The prevalence ratios were calculated by Poisson regression.

RESULTS

Thirty-eight (65.5%) preemies presented high adherence to micronutrient supplementation guidelines. At six months of corrected age, no preemie had vitamin A deficiency. The prevalences of anemia, iron deficiency and zinc deficiency were higher in the low-adherence group but also concerning in the high-adherence group. Preemies with low adherence to micronutrient supplementation guidelines were 2.5 times more likely to develop anemia and 3.1 times more likely to develop zinc deficiency. Low maternal education level increased the likelihood of nonadherence to all three supplements by 2.2 times.

CONCLUSIONS

Low maternal education level was independently associated with low adherence to iron, zinc and vitamin A supplementation guidelines in preemies, which impacted the prevalences of anemia and iron and zinc deficiencies at six months of corrected age.

Anti-oxidant profiles and markers of oxidative stress in preterm neonates

BACKGROUND

Preterm birth is associated with an increased oxidant burden which places these infants at a higher risk of injury.

AIMS

This prospective study aimed to assess levels of antioxidants and a marker of oxidative stress in preterm neonates.

OBJECTIVES

(i) To compare levels of anti-oxidants [vitamin A, vitamin E, catalase, total anti-oxidant status (TAS)] as well as malondialdehyde level (MDA) (a marker of lipid peroxidation) between preterm and full-term neonates; (ii) to determine changes in the values of measured vitamins at birth and at discharge among preterm neonates; and (iii) to compare levels of anti-oxidants with MDA levels in relation to complications of prematurity and outcome.

METHODS

The study was undertaken in 100 preterm neonates and 100 full-term neonates as a control group. MDA was estimated by a thiobarbituric acid-reactive technique; TAS was determined using a Randox assay kit; catalase activity was measured spectrophotometrically and vitamin A and E levels were estimated by high performance liquid chromatography.

RESULTS

The plasma levels of vitamin A, vitamin E, TAS and catalase were significantly lower in the preterm than in the full-term group (P < 0.01), and the plasma level of MDA was significantly higher in preterm than full-term neonates (P < 0.01). Vitamin A and E levels in preterm neonates were significantly higher at discharge than at birth (P < 0.01). Vitamin A, vitamin E and catalase levels at birth were significantly lower in patients who developed necrotizing enterocolitis or bronchopulmonary dysplasia than in those who did not.

CONCLUSION

Preterm neonates are exposed to increased oxidant stress at birth and are susceptible to anti-oxidant deficiencies. A higher dose of enteral vitamin A supplementation in preterm neonates might reduce morbidity and improve outcome. Further studies are warranted to evaluate the appropriate dose of oral vitamin E supplementation for preterm neonates.

Review of trace mineral requirements for preterm infants: what are the current recommendations for clinical practice?

Inadequate nutrient stores at birth are an inevitable consequence of being born prematurely. Preterm infants also have high nutrient requirements, which increase with earlier gestational ages. As a result, early nutrition intervention is required to prevent further deficits that, if not corrected, can affect growth and long-term outcomes. Preterm infants often require several weeks of parenteral nutrition (PN) support, which includes trace mineral supplementation. Trace minerals are considered essential nutrients, unable to be synthesized in the human body. Deficiencies of trace minerals have been reported, yet evidence-based guidelines for assessment and supplementation have not been clearly defined. Food and Drug Administration-approved parenteral trace mineral intake guidelines are more than 30 years old. In an effort to more clearly define trace mineral supplementation and monitoring guidelines for preterm infants, a review of literature was performed with the purpose to (1) summarize trace mineral roles in preterm infants, (2) describe clinical signs of deficiency and toxicity, and (3) present intake recommendations and considerations for preterm infants based on current available literature. Review of literature was completed using PubMed and Cochrane databases to find relevant studies specific to trace mineral requirements for preterm infants, trace mineral supplementation of PN, human milk fortifiers, and preterm infant formulas. Review of literature supports that trace mineral depletion can lead to clinical compromise in preterm infants; therefore, suggesting that every effort be made to ensure adequate provision of trace minerals is given to preterm infants. Practical considerations for the clinical nutrition management of preterm infants were also identified in this review.

Developmental regulation of antioxidant enzymes and their impact on neonatal lung disease

SIGNIFICANCE

Deficient antioxidant defenses and compromised ability to respond to oxidative stress burden the immature lung. Routine neonatal therapies can cause increased oxidative stress with subsequent injury to the premature lung. Novel therapeutic approaches to protect the premature lung are greatly needed.

RECENT ADVANCES

Live cell imaging with targeted redox probes allows for the measurement of subcellular oxidative stress and for comparisons of oxidative stress across development. Comprehension of subcellular and cell-type-specific responses to oxidative stress may influence the targeting of future antioxidant therapies.

CRITICAL ISSUES

Challenges remain in identifying the optimal cellular targets, degree of enzyme activity, and appropriate antioxidant therapy. Further, the efficacy of delivering exogenous antioxidants to specific cell types or subcellular compartments remains under investigation. Treatment with a nonselective antioxidant could unintentionally compromise cellular function or impact cellular defense mechanisms and homeostasis.

FUTURE DIRECTIONS

Genetic and/or biomarker screening may identify infants at the greatest risk for oxidative lung injury and guide the use of more selective antioxidant therapies. Novel approaches to the delivery of antioxidant enzymes may allow cell type- or cellular organelle-specific therapy. Improved comprehension of the antioxidant enzyme regulation across cell type, cell compartment, gender, and developmental stage is critical to the design and optimization of therapy.

Post-discharge nutrition and the VLBW infant: To supplement or not supplement?: a review of the current evidence

Due to advancements in neonatology, the survival of very-low-birth-weight infants, especially extremely low-birth-weight infants continues to rise. The goal of nutrition in these preterm infants is to match the intrauterine growth curves of the normally growing fetus. Despite this recommendation from the American Academy of Pediatrics Committee on Nutrition, neonatologists struggle daily to meet this goal, and as a result, postnatal growth failure and restriction are common. This article reviews post-discharge nutrition in the VLBW population, examining different types of post-discharge nutrition, current evidence, and future and remaining questions. In addition, recommendations are provided for post-discharge nutrition in this population.

Effect of type of heat treatment of breastmilk on folate content and pattern

BACKGROUND

Breastmilk is the recommended aliment for preterm infants. Milk banks provide donated breastmilk for the neonatal care of preterm infants when mother's own milk is not is available. To avoid pathogen transmission, donated breastmilk is heat-treated according to different procedures before administration. There is varying information on the effect of heat treatment on folate in breastmilk. Sufficient folate intake, however, is essential for normal growth and brain development. This study determined and compared the effects of different heat treatments on breastmilk folate content and pattern of individual folate forms.

MATERIALS AND METHODS

Donated Swedish breastmilk samples were heat-treated according to three procedures: two low temperature treatments (57°C, 23 minutes; 62.5°C, 12 minutes) and a rapid high temperature treatment (heating to 73°C in boiling water). The folate content and pattern were determined before and after treatment by high-performance liquid chromatography.

RESULTS

The folate content in 38 untreated Swedish breastmilk samples was 150±46 nmol/L. Two different folate vitamers were detected: 5-methyltetrahydrofolate (78±7%) and tetrahydrofolate (22±7%). Heat treatment affected only tetrahydrofolate stability and decreased folate content by 15-24%; however, the effects on folate content did not differ among the investigated heat treatment procedures.

CONCLUSIONS

Folate losses during heat treatment of human milk were considered acceptable. Yet, native folate content of heat-treated, non-fortified breastmilk supplied only 25% of the recommended daily intake for preterm infants.

Zinc supplementation reduces morbidity and mortality in very-low-birth-weight preterm neonates: a hospital-based randomized, placebo-controlled trial in an industrialized country

BACKGROUND

Zinc plays a pivotal role in the pathogenesis of many diseases and in body growth. Preterm neonates have high zinc requirements.

OBJECTIVE

The objective of the study was to investigate the efficacy of zinc supplementation in reducing morbidity and mortality in preterm neonates and to promote growth.

DESIGN

This was a prospective, double-blind, randomized controlled study of very-low-birth-weight preterm neonates randomly allocated on the seventh day of life to receive (zinc group) or not receive (control group) oral zinc supplementation. Total prescribed zinc intake ranged from 9.7 to 10.7 mg/d in the zinc group and from 1.3 to 1.4 mg/d in the placebo control group. The main endpoint was the rate of neonates with ≥ 1 of the following morbidities: late-onset sepsis, necrotizing enterocolitis, bronchopulmonary dysplasia, periventricular leucomalacia, and retinopathy of prematurity. Secondary outcomes were mortality and body growth.

RESULTS

We enrolled 97 neonates in the zinc group and 96 in the control group. Morbidities were significantly lower in the zinc group (26.8% compared with 41.7%; P = 0.030). The occurrence of necrotizing enterocolitis was significantly higher in the control group (6.3% compared with 0%; P = 0.014). Mortality risk was higher in the placebo control group (RR: 2.37; 95% CI: 1.08, 5.18; P = 0.006). Daily weight gain was similar in the zinc (18.2 ± 5.6 g · kg⁻¹ · d⁻¹) and control (17.0 ± 8.7 g · kg⁻¹ · d⁻¹) groups (P = 0.478).

CONCLUSION

Oral zinc supplementation given at high doses reduces morbidities and mortality in preterm neonates. This trial was registered in the Australian New Zealand Clinical Trial Register as ACTRN12612000823875.

Differential effects of docosahexaenoic acid on preterm and term placental pro-oxidant/antioxidant balance

Docosahexaenoic acid (DHA) supplementation in pregnancy may confer some clinical benefits; however, this compound can exert pro-oxidant effects. In this study, we investigated the effects of DHA on pro-oxidant/antioxidant balance in term and preterm placental explants, assessing oxidative stress marker concentrations, antioxidant capacity and pro-inflammatory cytokine production. Term (n=8) and preterm (n=9) placental explants were exposed to lipopolysaccharide (LPS, 1 ng/ml), DHA (1, 10 and 100 μM), and DHA and LPS simultaneously or pre-treated with DHA for 24 h prior to LPS treatment. The production of malondialdehyde (MDA, lipid peroxidation), 8-hydroxy-2-deoxy guanosine (8-OHdG, oxidative DNA damage) and pro-inflammatory cytokines (tumour necrosis factor α (TNFα), interleukin 6 and interferon-γ) and total antioxidant capacity were measured. DHA at a concentration of 100 μM induced oxidative stress in term placentas, while at all the three concentrations, it induced oxidative stress in preterm placentas. DHA and LPS resulted in reduced MDA levels in term (P<0.005) and preterm (P=0.004) placentas and reduced 8-OHdG levels in preterm placentas (P=0.035). DHA pre-treatment, but not co-treatment with LPS, reduced 8-OHdG levels (P<0.001) in term placentas. DHA increased antioxidant capacity only in term placentas (P<0.001), with lower antioxidant capacity being observed overall in preterm placentas compared with term placentas (P≤0.001). In term placentas, but not in preterm ones, DHA co-treatment and pre-treatment reduced LPS-induced TNFα levels. The ability of DHA to alter placental pro-oxidant/antioxidant balance is dependent on the DHA concentration used and the gestational age of the placental tissue. DHA has a greater capacity to increase oxidative stress in preterm placentas, but it offers greater protection against inflammation-induced oxidative stress in term placentas. This appears to be a result of DHA altering placental antioxidant capacity. These data have implications for the timing and concentration of DHA supplementation in pregnancy.

Parenteral nutrition additive shortages: the short-term, long-term and potential epigenetic implications in premature and hospitalized infants

Nutrition support practitioners are currently dealing with shortages of parenteral nutrition micronutrients, including multivitamins (MVI), selenium and zinc. A recent survey from the American Society of Enteral and Parenteral Nutrition (ASPEN) indicates that this shortage is having a profound effect on clinical practice. A majority of respondents reported taking some aggressive measures to ration existing supplies. Most premature infants and many infants with congenital anomalies are dependent on parenteral nutrition for the first weeks of life to meet nutritional needs. Because of fragile health and poor reserves, they are uniquely susceptible to this problem. It should be understood that shortages and rationing have been associated with adverse outcomes, such as lactic acidosis and Wernicke encephalopathy from thiamine deficiency or pulmonary and skeletal development concerns related to inadequate stores of Vitamin A and D. In this review, we will discuss the current parenteral shortages and the possible impact on a population of very low birth weight infants. This review will also present a case study of a neonate who was impacted by these current shortages.

Three distinct cases of copper deficiency in hospitalized pediatric patients

Although copper deficiency is a rare occurrence in the developed world, attention should be given to the proper supplementation of minerals to at-risk pediatric patients. This study presents 3 distinct cases of copper deficiency in hospitalized patients aged 14 months, 6 years, and 12 years. Two patients had short bowel syndrome, requiring prolonged parenteral nutrition or complex intravenous fluid supplementation. The third patient was severely malnourished. Copper deficiency manifested in all of our patients as either microcytic anemia or pancytopenia with myelodysplastic syndrome. Copper deficiency is an important diagnosis to be considered in patients with prematurity, parenteral nutrition dependency, malabsorption, and/or those with malnutrition. More studies are needed to establish appropriate amounts of copper supplementation to replenish copper stores in deficient patients.

Evaluation of human milk fortification from the time of the first feeding: effects on infants of less than 31 weeks gestational age

OBJECTIVE

To determine whether human milk fortification from the time of the first feeding significantly improves weight gain and bone mineral status in infants of <31 weeks estimated gestational age as compared with delayed or standard human milk fortification.

STUDY DESIGN

This was a retrospective pre-post design. In all, 95 infants born at <31 weeks estimated gestational age were compared. There were 53 infants in the early fortification group (EFG) and 42 infants in the delayed fortification group (DFG). They were compared with regard to weight gain at 34 weeks postmenstrual age (PMA), and their serum levels of calcium, phosphorus and alkaline phosphatase levels were compared as an indicator of bone mineral status. The practice change of fortifying all human milk given to preterm infants at <34 weeks PMA commenced in June 2009. The usual practice of fortification took place once an infant had reached a feeding volume of 50 to 100 ml kg(-1) per day. The new practice fortified all human milk with a powdered human milk fortifier to 24 calories per ounce, starting with the first feeding, no matter how small the volume.

RESULT

There were no differences in weight gain between the EFG and the DFG. The group that received fortification from the time of the first feeding were significantly less likely to have alkaline phosphatase levels >500 U l(-1) from 33 weeks PMA onward. There was no incidence of feeding intolerance with early fortification.

CONCLUSION

Fortification of human milk from the time of the first feeding does not affect weight gain at 34 weeks PMA, but is related to a lower incidence of elevated alkaline phosphate levels and does not cause feeding intolerance.

Longitudinal study on trace mineral compositions (selenium, zinc, copper, manganese) in Korean human preterm milk

We measured selenium, zinc, copper and manganese concentrations in the human milk of Korean mothers who gave birth to preterm infants, and compared these measurements with the recommended daily intakes. The samples of human milk were collected postpartum at week-1, -2, -4, -6, -8, and -12, from 67 mothers who gave birth to preterm infants (< 34 weeks, or birth weight < 1.8 kg). All samples were analyzed using atomic absorption spectrophotometry. The concentrations of selenium were 11.8 ± 0.5, 11.4 ± 0.8, 12.7 ± 0.9, 11.4 ± 0.8, 10.8 ± 0.9, and 10.5 ± 1.3 µg/L, zinc were 7.8 ± 0.5, 9.1 ± 0.8, 7.2 ± 0.9, 8.0 ± 0.8, 7.4 ± 0.9, and 6.6 ± 1.2 mg/L, copper were 506 ± 23.6, 489 ± 29.4, 384 ± 33.6, 356 ± 32.9, 303 ± 35.0, and 301 ± 48.0 µg/L and manganese were 133 ± 4.0, 127 ± 6.0, 125 ± 6.0, 123 ± 6.0, 127 ± 6.0, and 108 ± 9.0 µg/L at week-1, -2, -4, -6, -8, and -12, respectively. The concentrations of selenium and zinc meet the daily requirements but that of copper is low and of manganese exceeds daily requirements recommended by the American Academy of Pediatrics, Committee on Nutrition.

Vitamin D status among 4-month-old infants in New England: a prospective cohort study

BACKGROUND

Concerns over vitamin D deficiency in infants and children recently prompted the American Academy of Pediatrics to recommend increased supplementation. Few studies have examined vitamin D status in the same infants over time. Also, while many researchers label "breastfeeding" as a risk factor for vitamin D deficiency, few differentiate between any breastfeeding, exclusive breastfeeding, and supplemented or unsupplemented breastfeeders.

OBJECTIVE

To determine predictors of 25(OH)D deficiency at 4 months in a group of children previously tested at birth.

METHODS

We enrolled newborns from 2005 to 2007 at an urban Boston hospital. Maternal and infant blood samples were collected within 72 hours of birth. At 4 months, we obtained a second infant blood sample.

RESULTS

At 4 months, 11.9% of the 177 infants were vitamin D deficient compared to 37.5% at birth (25(OH)D <20 ng/mL). Median 25(OH)D was 35.2 ng/mL (range, 5-100.8; 95% confidence interval [CI], 32.8-37.6). At 4 months, 40% of unsupplemented infants were deficient. Lack of supplementation was significantly associated with increased risk of deficiency (adjusted odds ratio [AOR], 19.3; 95% CI, 4.80-77.2). Being outside at least 10 minutes a day, once per week, was protective (AOR, 0.12; 95% CI, 0.02-0.66), as was increasing gestational age (AOR, 0.36; 95% CI, 0.19-0.69). In 48.4% of patients, physicians failed to prescribe vitamin D at 2 months.

CONCLUSIONS

Despite inconsistent supplementation, a smaller proportion of infants were vitamin D deficient at 4 months than at birth. While supplemented breastfed infants were not at risk of deficiency, unsupplemented exclusively breastfed infants were at high risk of severe deficiency.

Future applications of antioxidants in premature infants

PURPOSE OF REVIEW

This review will examine the unique susceptibility of premature infants to oxidative stress, the role of reactive oxygen species (ROS) in the pathogenesis of common disorders of the preterm infant, and potential for therapeutic interventions using enzymatic and/or nonenzymatic antioxidants.

RECENT FINDINGS

Oxidative stress is caused by an imbalance between the production of ROS and the ability to detoxify them with the help of antioxidants. The premature infant is especially susceptible to ROS-induced damage because of inadequate antioxidant stores at birth, as well as impaired upregulation in response to oxidant stress. Thus, the premature infant is at increased risk for the development of ROS-induced diseases of the newborn, such as bronchopulmonary dysplasia, retinopathy of prematurity, necrotizing enterocolitis, and periventricular leukomalacia.

SUMMARY

Potential therapies for ROS-induced disease include both enzymatic and nonenzymatic antioxidant preparations. More research is required to determine the beneficial effects of supplemental antioxidant therapy.

Maturation of the antioxidant system and the effects on preterm birth

The study of the interplay of the generation of reactive oxygen and nitrogen species with their related antioxidant enzymes at the maternal-placental-fetal interfaces during normal and abnormal pregnancy is in its 'infancy'. Our understanding of the role of antioxidant systems during fetal and neonatal development is constantly changing with research better defining the biological roles of these highly reactive species and the maintenance of optimal oxidant/antioxidant balance. The antioxidant enzyme system is upregulated during the last 15% of gestation, a timeframe when non-enzymatic antioxidants are also crossing the placenta in increasing concentrations. These developmental changes provide for the transition from the relative hypoxia of intrauterine development to the oxygen-rich extrauterine environment. Preterm birth is associated with an increased oxidant burden which places these infants at much higher risk of injury. This is especially true since studies have failed to reveal significant induction of antioxidants in response to the increased generation of these reactive species. Improved understanding of these relationships will be necessary for the development of rational treatments aimed at improving pregnancy outcomes and reducing the burden of oxidative stress to premature newborns.