Bioavailability of dietary urea nitrogen in the breast-fed infant

Longitudinal Changes in Crude Protein and Amino Acids in Human Milk in Chinese Population: A Systematic Review

OBJECTIVE

More than 20% of the world population live in China, which has made significant achievement in human milk research. Part of the data that were published in Chinese were, however, unavailable to non-Chinese speakers. There was also no comprehensive overview of crude protein and amino acid levels in human milk in Chinese population. This systematic review aimed to compile the data on human milk crude protein and amino acid levels in Chinese population.

METHODS

After searching for and screening original research articles in both English and Chinese, 23 published from 1987 to 2019 were identified (18 in Chinese and 5 in English). The data were pooled into 9 defined lactation stages.

RESULTS

Crude protein and amino acids (protein bound plus nonprotein bound) concentrations gradually decreased during the first 60 postpartum days and remained relatively static thereafter. The concentrations and dynamic change of crude protein and amino acids were similar to those in other populations. By contrast, the longitudinal changes in free amino acids (nonprotein bound) were less clear due to the limited data available. Several common weaknesses were identified in these studies.

CONCLUSIONS

Our study represented the most comprehensive overview on crude protein and amino acid concentrations in human milk in Chinese population, and enhanced the knowledge of protein and amino acid intakes and requirements by Chinese infants.

Nutrition from the Inside Out

Nearly 50 years ago, I set out to investigate the clinical problem of hypoglycemia in children with illnesses that limited their food intake. My goal was to gather accurate and precise measurable data. At the time, I wasn't interested in nutrition as a discipline defined in its more general or popular sense. To address the specific problem that interested me required development of entirely new methods based on stable, nonradioactive tracers that satisfied the conditions of accuracy and precision. At the time, I had no inclination of the various theoretical and practical problems that would have to be solved to achieve this goal. Some are briefly described here. Nor did I have the slightest idea that developing the field would result in a fundamental change in how human clinical investigation was conducted, with the eventual replacement of radiotracers with stable isotopically labeled ones, even for adult clinical investigation. Additionally, I had no inclination that the original questions would open avenues to much broader questions of practical nutritional relevance. Moreover, only much later as the editor of The American Journal of Clinical Nutrition did I appreciate the policy implications of how nutritional data are presented in the scientific literature. At least in part, less accurate and precise measurements and less than full transparency in reporting nutritional data have resulted in widespread debate about the public policy recommendations and guidelines that are the intended result of collecting the data in the first place. This article provides a personal recollection (with all the known faults of self-reporting and retrospective memory) of the journey that starts with measurement certainty and ends with policy uncertainty.

In vivo measurement of ureagenesis with stable isotopes

We have utilized stable isotopes to measure in vivo rates of ureagenesis. In one testing procedure, 15NH4Cl was administered orally to controls and to heterozygotes for ornithine transcarbamylase deficiency. Controls produced [15N]urea at a rate that was greater than that of symptomatic carriers, but indistinguishable from that of asymptomatic carriers. In contrast, both symptomatic and asymptomatic heterozygotes produced [5-15N]glutamine more rapidly than the controls. Ureagenesis could also be measured by administering sodium [1-13C]acetate to a healthy adult and measuring subsequent formation of [13C]urea. The latter approach involves the use of isotope ratio mass spectrometry to determine isotopic abundance. This technique is much more sensitive than gas chromatography-mass spectrometry for the measurement of isotopic label, a consideration that makes the method more suitable for the study of subjects in whom ureagenesis is severely compromised, for example the human male neonate with a near complete deficiency of ornithine transcarbamylase.

Properties of human milk and their relationship with maternal nutrition

The composition of human milk varies over the course of lactation and in each individual. The volume of breast milk produced is related to the weight of the infant. Human milk is markedly different from cows' milk, both in terms of macronutrients and micronutrients. This includes the types of fatty acids present and factors affecting their absorption. The types of proteins present and their relative proportions and both qualitative and quantitative differences in the non-protein nitrogen fraction. There is much less lactose in cows' milk than breast milk and the oligosaccharide fraction is very different. Their are major differences in content and absorption rates of vitamins and minerals from breast milk compared to cows' milk or formula milk. Vitamin D and vitamin K status are possible problems for the breast-fed infant in certain circumstances. The nutritional status of the mother appears to influence fat concentration and thus the energy content of breast milk as well as its fatty acid composition and immunological properties. There is no coherent evidence, however, that the protein or lactose concentrations are greatly affected. There is some evidence that the concentration of vitamins in the breast milk are influenced by the mother's intake. Minerals are less variable, with the exception of selenium. The response of the infant to human and formula milk differs with respect to endocrine function, stool motility, immune function and renal function. Infant formula milks are designed to mimic human milk as much as possible, but this is unlikely to ever be completely successful. A number of important compositional differences between human milk and formula milk remain. This includes the types and proportions of fatty acids present (which may be of developmental importance), the nature of the non-protein nitrogen component (also possible developmental importance) and the presence of immunoglobulins and fibronectin (which may protect the infant against infection).

In vivo nitrogen metabolism in ornithine transcarbamylase deficiency

We developed a new technique that monitors metabolic competency in female heterozygotes for ornithine transcarbamylase deficiency (OTCD). The method uses mass spectrometry to measure conversion of (15)NH4Cl to [15N]urea and [5-(15)N]glutamine following an oral load of (15)NH4Cl. We found that heterozygotes converted significantly less NH3 nitrogen to urea, with this difference being particularly obvious for symptomatic carriers, in whom the blood [15N]urea concentration (mM) was significantly less than control values at most time points. The blood concentration of [5-(15)N]-glutamine (microM) was significantly higher in both asymptomatic and symptomatic heterozygotes than it was in the control subjects. The administration of a test dose of sodium phenylbutyrate to the control group did not affect the rate of [15N]urea formation. We conclude: (a) This test effectively monitors in vivo N metabolism and might obviate the need for liver biopsy to measure enzyme activity in OTCD; (b) Asymptomatic OTCD carriers form urea at a normal rate, indicating that ureagenesis can be competent even though enzyme activity is below normal; (c) Although ostensibly asymptomatic OTCD carriers form urea at a normal rate, their nitrogen metabolism is still abnormal, as reflected in their increased production of [5-(15)N]glutamine; and (d) This new test may be important for monitoring the efficacy of novel treatments for OTCD, e.g., liver transplantation and gene therapy.

Diurnal pattern of the interrelationships among leucine oxidation, urea production, and hydrolysis in humans

We investigated in six healthy adult men, who received an adequate intake of protein (1 g.kg-1.day-1), the relationship among urea production, excretion, and hydrolysis. At the end of a 6-day diet-adjustment period, subjects were studied using a 24-h continuous intravenous [1-13C]leucine and [15N,15N]urea tracer protocol (A. E. El-Khoury, N. K. Fukagawa, M. Sánchez, R. H. Tsay, R. E. Gleason, T. E. Chapman, and V. R. Young. Am. J. Clin. Nutr. 59: 1000-1011, 1994) to determine rates of irreversible protein nitrogen loss and urea kinetics. By combining leucine and urea kinetic data, we found a significant degree of urea hydrolysis over the 24-h period but no evidence to support the thesis that there is a net retention or "salvage" of the urea nitrogen liberated. Our measurements revealed little or no urea hydrolysis during the fed 12-h period of the 24-h tracer protocol but substantial hydrolysis during the 12-h fasting phase. Furthermore, a mass balance model and calculations (APPENDIX) indicated that nitrogen salvage, if any, is quantitatively indistinguishable from insensible nitrogen losses and aggregate estimation errors, accounting for no more than 5% of the nitrogen intake. We conclude that urea hydrolysis, via the intestinal microflora, although representing a component of the overall cycles of nitrogen flow within the body, does not contribute via a net retention of amino nitrogen to the maintenance of body nitrogen homeostasis in healthy adults consuming an adequate diet.

Urea production in normal breast-fed infants measured with primed/intermittent oral doses of [15N, 15N]urea

Urea kinetics were measured on 11 occasions in six normal, breast-fed infants aged 29-88 days. Prime and intermittent oral doses of [15N, 15N]urea with measurement of enrichment of urea in urine were used. The rate at which urea appeared in the urea pool was 265 mgN/kg per hour, 85% of which derived from endogenous production and 15% from the diet. Urinary excretion of urea was 87 mgN/kg per hour. Therefore, 60% of the urea entering the pool each day was hydrolysed by the metabolic activity of the colonic microflora and the nitrogen was made available for further metabolic interaction. The rate of urea appearance and the extent to which urea nitrogen was salvaged were greater in infants under 6 weeks than in those over 6 weeks, indicating that urea kinetics is a more active process at an early age, and slows with time. With respect to factors influencing urea kinetics, the apparently conflicting results which have appeared in the literature may be explained. The results may help explain the growth of breast-fed infants on low protein intakes.

Carbon dioxide formation and elimination in man. Recent theories and possible consequences

Systemic metabolism results in a production of not only carbon dioxide, water and urea but also bicarbonate ions. Most of these bicarbonate ions are generated during the catabolism of glutamine. In order to be eliminated as carbon dioxide in the lungs bicarbonate ions must be protonised. This protonisation of the bicarbonate ion seems to take place in a number of tissue compartments in which acid-base balance is maintained. One of the most important processes for protonisation of the bicarbonate ion is the hepatic ureagenesis from ammonia/ammonium ions. A substantial part of the ammonia/ammonium ions are generated during the catabolism of amino acids. Terminal oxidation of glutamine in the gut seems to be of great significance for this process. In certain conditions the enteric generation of ammonium ions seems so important that an ATP-driven enterohepatic recirculation of ammonium ions/urea constituting an amplifying mechanism for the protonisation of the bicarbonate ion is motivated.

Protein nutrition during infancy. An update

Good nutrition is essential during the critical period of infancy to promote the child's optimal growth and development. Proteins in human milk are discussed. Protein requirement and recommended dietary intake of healthy term infants during the first 6 months are reviewed. Recommendations for protein content in infant starting formulas and weaning are also discussed.

Urea kinetics in neonates receiving total parenteral nutrition

Urea kinetics were measured on 10 occasions in eight neonates who had not received an oral intake from birth and were maintained on total parenteral nutrition. After a prime/intermittent oral dose of 15N15N-urea over 14 hours urine was collected every three to four hours, urea isolated, and kinetics determined from the plateau level of enrichment in urea, measured by isotope ratio mass spectrometry. The total parenteral nutrition provided 393 kJ (94 kcal)/kg/day and 360 mg nitrogen/kg/day. Urea production was mean (SD) 84 (44) mg nitrogen/kg/day, or 50% of intake. Urinary excretion of urea, 39 (16) mg nitrogen/kg/day, was 40% of production. Therefore 54% of urea production was salvaged through the lower bowel, 45 (35) mg nitrogen/kg/day. It is concluded that even in infants who have never had a regular dietary intake the microflora of the lower bowel is sufficiently developed to salvage urea nitrogen for further metabolic interaction, however it is not clear whether the rate of salvage is adequate to satisfy the metabolic demand.

Pancreatic insufficiency, growth, and nutrition in infants identified by newborn screening as having cystic fibrosis

To evaluate the impact of early pancreatic insufficiency on growth and nutritional status in cystic fibrosis, we studied 49 infants identified by a newborn screening program. Pancreatic insufficiency, determined by increased 72-hour fecal fat excretion, was present in 59% (23/39) of infants at diagnosis (7.0 +/- 0.8 weeks; mean +/- SEM). Before initiation of pancreatic enzyme replacement, growth and nutritional status of pancreatic-insufficient (n = 16) and pancreatic-sufficient (n = 13) infants were compared. Pancreatic-insufficient infants gained less weight from birth to diagnosis (13.4 +/- 3.4 vs 22.3 +/- 4.0 gm/day; p = 0.05), had decreased triceps skin-fold thicknesses (4.5 +/- 0.3 vs 6.1 +/- 0.4 mm; p less than 0.005), and had lower blood urea nitrogen (3.07 +/- 0.42 vs 4.62 +/- 0.65 mg/dl; p = 0.02) and albumin (2.99 +/- 0.14 vs 3.54 +/- 0.14 gm/dl; p less than 0.01) levels despite higher gross calorie (154 +/- 8 vs 116 +/- 13 kcal/kg per day; p less than 0.01) and protein intakes (2.81 +/- 0.21 vs 2.14 +/- 0.33 gm/kg per day; p = 0.03). Fecal nitrogen loss was correlated with fat loss (r = 0.79; p less than 0.001). Fat malabsorption was present in 79% (30/38) and 92% (33/36) of infants tested at 6 months and 12 months of age, respectively, indicating that pancreatic insufficiency persists and increases in frequency throughout infancy. We conclude that pancreatic insufficiency is prevalent in young infants with cystic fibrosis and has a significant impact on growth and nutrition.

Bioavailability of urea nitrogen for the low birthweight infant

Previous studies have demonstrated increased retention (40%) of dietary urea nitrogen by term infants recovering from infection compared to healthy infants (13%), possibly due to a higher requirement for nitrogen. Since low birthweight infants also have a high requirement for nitrogen, the bioavailability of urea nitrogen was investigated in low birthweight infants using 15N,15N-urea. Four low birthweight infants (gestational age = 30 +/- 2.2 weeks [mean +/- SD], birthweight = 1.4 +/- 0.3 kg) were fed formula enriched with 15N,15N-urea. Metabolic balance studies (72 hours) were performed with urine and fecal collections. Nitrogen was quantitated by Kjeldahl analysis and 15N,15N-urea by gas chromatography/mass spectrometry. Mean nitrogen intake was 489 +/- 32 mg/kg/d, with 75% nitrogen absorption and 62% nitrogen retention. Maximum urinary enrichment was 8%. Cumulative 15N,15N-urea excretion was 72%, resulting in 28% retention. Thus the bioavailability of urea nitrogen for low birthweight infants appears to be intermediate between compromised and normal term infants.

Non-protein nitrogen and true protein in infant formulas

Protein and nitrogen (N) requirements of infants and the optimum protein level of infant formulas are still under debate. Human milk (HM) N is considered adequate although 25% of the N is provided as non-protein nitrogen (NPN), half in the form of urea. Soluble N, insoluble N, NPN and urea N were determined in HM and cow's milk (CM), 5 CM-based infant formulas, 4 soy protein-based formulas (SF), and manufacturers' skim milk and whey protein sources. Total, peptide and free amino acids were also determined in all samples. Levels of NPN and urea N in formulas were highly dependent on the type of whey used, with ion-exchange whey being highest, followed by electrodialyzed and ultrafiltered whey, respectively. SF contained very little NPN with the exception of Soyalac. Consequently, true protein [(Total N-NPN) x 6.38] was lower than the reported levels in several formulas. Levels of peptide and free amino acids were also affected by the method of whey preparation. While it has been recognized that "casein-predominant" CM formulas will have different effects on metabolic indices than "whey-predominant" formulas, this study demonstrates that there are also pronounced differences among "whey-predominant" formulas.