Key nutrients and growth factors for the neonatal gastrointestinal tract

Time to Reach Full Enteral Feeding and Its Predictors among Very Low Birth Weight Neonates Admitted in the Neonatal Intensive Care Unit: A Follow-Up Cohort Study

Background

Feeding is crucial for very low birth weight neonates to grow and develop properly. This study aims to determine the time to achieve full enteral feeding and predictors among neonates admitted at Felege Hiwot Comprehensive Specialized Hospital.

Methods

An institutional retrospective follow-up study design was conducted among 332 very low birth weight neonates from July 1, 2018, to June 30, 2021. Samples were selected through a computer-generated simple random sampling method, and the data were entered into Epi data version 4.6 and then exported to STATA version 16 for analysis. Kaplan-Meier with the log-rank test was used to test for the presence of difference in survival among predictor variables. Model goodness of fit and assumptions were checked by the Cox-Snell residual and the global test, respectively. Variables with p value <0.25 in the bi-variable analysis were fitted to the multivariable Cox-proportional hazard model. Finally, the adjusted hazard ratio (AHR) with 95% CI was computed, and variables with a p value less than 0.05 in the multivariable Cox regression analysis were considered significant predictors of time to reach full enteral feeding.

Results

A total of 332 neonates were followed for 2,132 person days of risk time and 167 (50.3%) of very low birth weight neonates started full enteral feeding. The overall incidence rate of full enteral feeding was 7.8 per 100 person day observations. The median survival time was 7 days. Very low birth weight neonates delivered from pregnancy-induced hypertension-free mothers (AHR: 2.1; 95% CI: 1.12, 3.94), gestational age of ≥33 weeks (AHR: 5,; 95% CI: 2.29, 11.13), kangaroo mother care initiated (AHR: 1.4; 95% CI: 1.01, 2.00), avoiding prefeed residual aspiration (AHR: 1.42; 95% CI: 1.002-2.03), and early enteral feeding (AHR: 1.5; 95% CI: 1.03, 2.35) were significant predictors of full enteral feeding.

Conclusions

According to this study, the time to achieve full enteral feeding was relatively short. Therefore, healthcare professionals should emphasize achieving full enteral feeding and address hindering factors to save the lives of VLBW neonates.

Review: A systematic review of the effects of functional amino acids on small intestine barrier function and immunity in piglets

The need to reduce the use of antibiotics and zinc oxide at the pharmacological level, while preserving the performance of postweaning piglets, involves finding adequate nutritional strategies which, coupled with other preventive strategies, act to improve the sustainability of the piglet-rearing system. Amino acids (AAs) are the building blocks of proteins; however, they also have many other functions within the body. AA supplementation, above the suggested nutritional requirement for piglets, has been investigated in the diets of postweaning piglets to limit the detrimental consequences occurring during this stressful period. A systematic review was carried out to summarise the effects of AAs on gut barrier function and immunity, two of the parameters contributing to gut health. An initial manual literature search was completed using an organised search strategy on PubMed, utilising the search term " AND ". These searches yielded 302 articles (published before October 2021); 59 were selected. Based on the method for extracting data (synthesis of evidence), this review showed that L-Arginine, L-Glutamine and L-Glutamate are important functional AAs playing major roles in gut morphology and immune functions. Additional benefits of AA supplementation, refereed to a supplementation above the suggested nutritional requirement for piglets, could also be observed; however, data are needed to provide consistent evidence. Taken together, this review showed that supplementation with AAs during the weaning phase supported a plethora of the physiological functions of piglets. In addition, the data reported confirmed that each amino acid targets different parameters related to gut health, suggesting the existence of potential synergies among them.

[Evidence-based standardized nutrition protocol can shorten the time to full enteral feeding in very preterm/very low birth weight infants]

OBJECTIVES

To investigate whether evidence-based standardized nutrition protocol can facilitate the establishment of full enteral nutrition and its effect on short-term clinical outcomes in very preterm/very low birth weight infants.

METHODS

A retrospective analysis was performed on the medical data of 312 preterm infants with a gestational age of ≤32 weeks or a birth weight of <1 500 g. The standardized nutrition protocol for preterm infants was implemented in May 2020; 160 infants who were treated from May 1, 2019 to April 30, 2020 were enrolled as the control group, and 152 infants who were treated from June 1, 2020 to May 31, 2021 were enrolled as the test group. The two groups were compared in terms of the time to full enteral feeding, the time to the start of enteral feeding, duration of parenteral nutrition, the time to recovery to birth weight, the duration of central venous catheterization, and the incidence rates of common complications in preterm infants.

RESULTS

Compared with the control group, the test group had significantly shorter time to full enteral feeding, time to the start of enteral feeding, duration of parenteral nutrition, and duration of central venous catheterization and a significantly lower incidence rate of catheter-related bloodstream infection (P<0.05). There were no significant differences between the two groups in the mortality rate and the incidence rate of common complications in preterm infants including grade II-III necrotizing enterocolitis (P>0.05).

CONCLUSIONS

Implementation of the standardized nutrition protocol can facilitate the establishment of full enteral feeding, shorten the duration of parenteral nutrition, and reduce catheter-related bloodstream infection in very preterm/very low birth weight infants, without increasing the risk of necrotizing enterocolitis.

Delayed introduction of progressive enteral feeds to prevent necrotising enterocolitis in very low birth weight infants

BACKGROUND

Enteral feeding for very preterm or very low birth weight (VLBW) infants is often delayed for several days after birth due to concern that early introduction of feeding may not be tolerated and may increase the risk of necrotising enterocolitis. Concerns exist, however, that delaying enteral feeding may diminish the functional adaptation of the gastrointestinal tract and prolong the need for parenteral nutrition with its attendant infectious and metabolic risks.

OBJECTIVES

To determine the effects of delayed introduction of progressive enteral feeds on the risk of necrotising enterocolitis, mortality and other morbidities in very preterm or VLBW infants.

SEARCH METHODS

Search strategies were developed by an information specialist in consultation with the review authors. The following databases were searched in October 2021 without date or language restrictions: CENTRAL (2021, Issue 10), MEDLINE via OVID (1946 to October 2021), Embase via OVID (1974 to October 2021), Maternity and Infant Care via OVID (1971 to October 2021), CINAHL (1982 to October 2021). We also searched for eligible trials in clinical trials databases, conference proceedings, previous reviews, and reference lists of retrieved articles.

SELECTION CRITERIA

Randomised controlled trials that assessed the effects of delayed (four or more days after birth) versus earlier introduction of progressive enteral feeds on necrotising enterocolitis, mortality and other morbidities in very preterm or VLBW infants.

DATA COLLECTION AND ANALYSIS

Two review authors separately evaluated trial risk of bias, extracted data, and synthesised effect estimates using risk ratio (RR), risk difference (RD), and mean difference. We used the GRADE approach to assess the certainty of evidence for effects on necrotising enterocolitis, mortality,  feed intolerance, and invasive infection.

MAIN RESULTS

We included 14 trials in which a total of 1551 infants participated. Potential sources of bias were lack of clarity on methods to generate random sequences and conceal allocation in half of the trials, and lack of masking of caregivers or investigators in all of the trials. Trials typically defined delayed introduction of progressive enteral feeds as later than four to seven days after birth and early introduction as four days or fewer after birth. Infants in six trials (accounting for about half of all of the participants) had intrauterine growth restriction or circulatory redistribution demonstrated by absent or reversed end-diastolic flow velocities in the fetal aorta or umbilical artery.  Meta-analyses showed that delayed introduction of progressive enteral feeds may not reduce the risk of necrotising enterocolitis (RR 0.81, 95% confidence interval (CI) 0.58 to 1.14; RD -0.02, 95% CI -0.04 to 0.01; 13 trials, 1507 infants; low-certainty evidence due risk of bias and imprecision) nor all-cause mortality before hospital discharge (RR 0.97, 95% CI 0.70 to 1.36; RD -0.00, 95% CI -0.03 to 0.03; 12 trials, 1399 infants; low-certainty evidence due risk of bias and imprecision). Delayed introduction of progressive enteral feeds may slightly reduce the risk of feed intolerance (RR 0.81, 95% CI 0.68 to 0.97; RD -0.09, 95% CI -0.17 to -0.02; number needed to treat for an additional beneficial outcome = 11, 95% CI 6 to 50; 6 trials, 581 infants; low-certainty evidence due to risk of bias and imprecision) and probably increases the risk of invasive infection (RR 1.44, 95% CI 1.15 to 1.80; RD 0.10, 95% CI 0.04 to 0.15; number needed to treat for a harmful outcome = 10, 95% CI 7 to 25; 7 trials, 872 infants; moderate-certainty evidence due to risk of bias).  AUTHORS' CONCLUSIONS: Delaying the introduction of progressive enteral feeds beyond four days after birth (compared with earlier introduction) may not reduce the risk of necrotising enterocolitis or death in very preterm or VLBW infants. Delayed introduction may slightly reduce feed intolerance, and probably increases the risk of invasive infection.

l-Arginine Alleviates Hydrogen Peroxide-Induced Oxidative Damage in Ovine Intestinal Epithelial Cells by Regulating Apoptosis, Mitochondrial Function, and Autophagy

BACKGROUND

Previous studies demonstrated that dietary l-arginine (Arg) alters the equilibrium between reactive oxygen species (ROS) generation and biological defenses to resist oxidant-induced toxicity. Whether supplying Arg can protect ovine intestinal epithelial cells (OIECs) from hydrogen peroxide (H2O2)-induced oxidative damage is unclear.

OBJECTIVES

The current study aimed to examine the effect of Arg on mitophagy, mitochondrial dysfunction, and apoptosis induced by H2O2 in OIECs.

METHODS

The OIECs were incubated in Arg-free DMEM supplemented with 100 μM Arg (CON) or 350 μM Arg (ARG) alone or with 150 μM H2O2 (CON + H2O2, ARG + H2O2) for 24 h. Cellular apoptosis, mitochondrial function, autophagy, and the related categories of genes and proteins were determined. All data were analyzed by ANOVA using the general linear model procedures of SAS (SAS Institute) for a 2 × 2 factorial design.

RESULTS

Relative to the CON and ARG groups, H2O2 administration resulted in 44.9% and 26.5% lower (P < 0.05) cell viability but 34.7% and 61.8% greater (P < 0.05) ROS concentration in OIECs, respectively. Compared with the CON and CON + H2O2 groups, Arg supplementation led to 40.7% and 28.8% lower (P < 0.05) ROS concentration but 14.9%-49.0% and 29.3%-64.1% greater (P < 0.05) mitochondrial membrane potential, relative mitochondrial DNA content, and complex (I-IV) activity in OIECs, respectively. Compared with the CON and CON + H2O2 groups, Arg supplementation led to 33.9%-53.1% and 22.4%-49.1% lower (P < 0.05) mRNA abundance of proapoptotic genes, respectively. Relative to the CON and CON + H2O2 groups, Arg supplementation resulted in 33.0%-59.2% and 14.6%-37.7% lower (P < 0.05) abundance of proapoptotic, mitophagy, and cytoplasmic cytochrome c protein, respectively.

CONCLUSIONS

Supply of Arg protects OIECs against H2O2-induced damage partly by improving mitochondrial function and alleviating cellular apoptosis and autophagy.

Characterization of a Swine Model of Birth Weight and Neonatal Nutrient Restriction

Background

Evidence indicates that birth weight and neonatal nutrition have lifelong effects. Animal models are required to improve our understanding of these factors.

Objectives

We aimed to develop and validate a swine model of birth weight and neonatal undernutrition.

Methods

At birth, a total of 112 piglets were identified as low (LBW; 1.22 ± 0.28 kg SEM) or normal birth weight (NBW; 1.70 ± 0.27 kg). From day 3 to weaning (day 28), piglets received normal nutrition (NN) or restricted nutrition (RN) via intermittent suckling, where piglets were isolated from the sow for 6 h/d. After weaning, pigs were fed a common diet for 28 d. Body weight (BW) was determined for the duration of the study. On days 28 and 56, empty carcass, viscera, and individual organ weights were determined in 8 pigs/treatment.

Results

LBW pigs remained smaller than NBW pigs, regardless of nutrient restriction (P &lt; 0.05). Within birth weight category, RN reduced BW by day 7 after birth, which was maintained until weaning (P &lt; 0.05); however, at 7 d postweaning there was no difference in BW due to RN (P &gt; 0.05). At weaning, empty carcass, viscera, heart, liver, and lung weights were lower in LBW than in NBW pigs, whereas empty carcass, heart, small intestine, liver, kidneys, lung, and spleen weights were lower in RN than in NN pigs (P &lt; 0.05). Brain weight was highest in NBW-NN and lowest in NBW-RN, with LBW intermediate, regardless of nutrient restriction (P &lt; 0.05). Postweaning, LBW had lower empty carcass, viscera, heart, stomach, large intestine, liver, and kidney weights than NBW, whereas RN had a higher small intestine weight than NN (P &lt; 0.05).

Conclusions

Intermittent suckling is an effective means of inducing nutrient restriction in a swine model.

Early total enteral feeding in stable preterm infants: a systematic review and meta-analysis

OBJECTIVE

To evaluate safety and feasibility of early total enteral feeding (ETEF) in stable preterm infants.

STUDY DESIGN

Systematic review and meta-analysis of randomized trials comparing incidence of necrotizing enterocolitis (NEC) and feeding intolerance between ETEF and slow rates of enteral feed advancement.

RESULTS

Four trials involving 393 very low birth weight (VLBW) infants with birth weight >1000-1200 g were included. Meta-analyses did not show statistical difference in risks for NEC (RR 0.87, 95% CI 0.19-3.98) and feeding intolerance (RR 0.78, 95% CI 0.39-1.59). ETEF resulted in lower risk of late-onset sepsis (RR: 0.43, 95% CI: 0.30-0.61). Length of hospital stay was reduced in ETEF (mean difference -1.31 days, 95% CI: -1.54 to -1.07).

CONCLUSIONS

ETEF appears to be safe and feasible in stable VLBW infants with birth weight >1000-1200 g. A large randomized trial is needed to confirm benefits.

Preterm Birth Has Effects on Gut Colonization in Piglets Within the First 4 Weeks of Life

OBJECTIVES

Preterm neonates have an immature gastrointestinal tract and show an altered bacterial colonization of the gut. However, it is not clear if such immature gut microbiota (GM) colonization is induced by specific delivery, diet, environment, and/or host factors related to preterm birth. Using piglets as models for infants, we hypothesized that both shortened gestational age (GA) and start of enteral feeding affect GM composition after caesarean delivery and rearing in identical environments.

METHODS

Caesarean-delivered preterm and term pigs were reared in incubators and fed total parenteral nutrition (TPN) or gradually increasing early enteral feeding (EEF) for 5 days, followed by full enteral feeding with bovine milk until day 26. GM composition was determined by 16S rRNA gene-amplicon sequencing and luminal short-chain fatty acids (SCFAs) by GC-MS.

RESULTS

Both GA and EEF feeding affected GM composition on day 5, but only the GA effect persisted until day 26. On day 5, Enterobacteriaceae were dominant, with Lachnospiraceae members also being abundant. Enterobacteriaceae still dominated the GM at day 26 but with higher Akkermansia relative abundance in term pigs. Colonic concentrations of acetate and propionate were higher, and formate lower in term pigs, relative to preterm pigs on day 26.

CONCLUSIONS

Preterm and term piglets, born and reared in similar ways, show differences in GM colonization during the first 4 weeks of life, which may play a role for early and later gut dysfunction resulting from preterm birth.

Modifiable Risk Factors in Necrotizing Enterocolitis

Multicenter groups have reported reductions in the incidence of necrotizing enterocolitis (NEC) among preterm infants over the past 2 decades. These large-scale prevalence studies have coincided with reports from multicenter consortia and single centers of modifications in practice using quality-improvement techniques aimed at either reducing NEC risk specifically or reducing risk of mortality and multiple morbidities associated with extreme prematurity. The modifications in practice have been based on mechanistic studies, epidemiologic association data, and clinical trials. Recent reports from centers modifying practice to reduce NEC are reviewed and select modified/modifiable practices discussed.

l-Arginine Protects Ovine Intestinal Epithelial Cells from Lipopolysaccharide-Induced Apoptosis through Alleviating Oxidative Stress

This research aims to explore the effect of l-arginine (Arg) upon lipopolysaccharide (LPS)-induced induction of the oxidative stress as well as subsequent apoptosis within ovine intestinal epithelial cells (IOECs). Through a 16 h incubation, cells were divided into four groups and the medium was replaced with different medium as follows: (1) control (Con), Arg-free Dulbecco's modified Eagle's F12 Ham medium (DMEM); (2) Arg treatment, Arg-free DMEM supplemented with 100 μM Arg; (3) LPS treatment, Arg-free DMEM supplemented with 10 μg/mL LPS; (4) LPS with Arg treatment, Arg-free DMEM supplemented with both 10 μg/mL LPS and 100 μM Arg. After culturing for 24 h in different mediums, some characteristics of cells in the four groups were measured. Addition of Arg increased cell viability induced with LPS compared with the LPS group ( p < 0.05). Arg significantly decreased the release of dehydrogenase (LDH) and the production of malonaldehyde (MDA) ( p < 0.05) within IOECs challenged by the LPS. Compared with the LPS group, cells treated with Arg and Arg + LPS increased ( p < 0.05) mRNA as well as protein expression of glutathione peroxidase 1 (GPx1), catalase (CAT), superoxide dismutase 2 (SOD2), B-cell lymphoma 2 (Bcl2), quinone oxidoreductase 1 (NQO1), heme oxygenase (HO-1), and nuclear factor erythroid 2-related factor 2 (Nrf2). IOEC treatment with Arg reduced significantly ( p < 0.05) apoptosis induced by the LPS (12.58 ± 0.79%). The results showed that Arg promoted the protein expression of Nrf2, up-regulated expression of the phase II metabolizing enzymes (NQO1 and HO-1), as well as antioxidative enzymes (GPx1, CAT, and SOD2) for alleviating oxidative injury and protected IOECs from LPS-induced apoptosis.

Effect of dietary soy oil, glucose, and glutamine on growth performance, amino acid profile, blood profile, immunity, and antioxidant capacity in weaned piglets

Weaning stress results in gastrointestinal dysfunction and depressed performance in pigs. This study aimed to investigate the effect of soy oil, glucose, and glutamine on the growth and health of weaned piglets. Compared with those in the glutamine group, piglets in the glucose and soy oil groups had greater average daily gain, average daily feed intake, and gain: feed ratio from day 0 to 14, and gain: feed ratio for the overall period. There were no differences with regard to serum amino acids among the three groups on day 14, except glycine and threonine. The serum concentration of histidine, serine, threonine, proline, and cysteine was the highest in the glutamine group, while the content of glycine and lysine in the soy oil group on day 28 was the highest among all groups. Piglets fed with glutamine had greater serum glucose and creatinine on day 14, high-density lipoprotein on day 28, and serum IgG and IgM on day 28. Piglets in the glutamine group demonstrated lower serum total superoxide dismutase on day 14 and 28; however, they demonstrated higher total superoxide dismutase and total antioxidant capacity in the duodenum and ileum on day 14. Weaned pigs supplemented with glucose or soy oil demonstrate better growth performance possibly due to their enhanced feed intake, whereas those supplemented with glutamine may have improved immunity and intestinal oxidative capacity.

Breast milk microRNAs harsh journey towards potential effects in infant development and maturation. Lipid encapsulation can help

The possibility that diet-derived miRNAs survive the gastrointestinal tract and exert biological effects in target cells is triggering considerable research in the potential abilities of alimentary preventive and therapeutic approaches. Many validation attempts have been carried out and investigators disagree on several issues. The barriers exogenous RNAs must surpass are harsh and adequate copies must reach target cells for biological actions to be carried out. This prospect opened a window for previously unlikely scenarios concerning exogenous non-coding RNAs, such as a potential role for breast milk microRNAs in infants' development and maturation. This review is focused on the thorny path breast milk miRNAs face towards confirmation as relevant role players in infants' development and maturation, taking into consideration the research carried out so far on the uptake, gastrointestinal barriers and potential biological effects of diet-derived miRNAs. We also discuss the future pharmacological and pharma-nutritional consequences of appropriate miRNAs research.

The Energy Costs of Prematurity and the Neonatal Intensive Care Unit (NICU) Experience

Premature neonates are in an energy deficient state due to (1) oxygen desaturation and hypoxia events, (2) painful and stressful stimuli, (3) illness, and (4) neurodevelopmental energy requirements. Failure to correct energy deficiency in premature infants may lead to adverse effects such as neurodevelopmental delay and negative long-term metabolic and cardiovascular outcomes. The effects of energy dysregulation and the challenges that clinicians in the Neonatal Intensive Care Unit (NICU) face in meeting the premature infant's metabolic demands are discussed. Specifically, the focus is on the effects of pain and stress on energy homeostasis. Energy deficiency is a complex problem and requires a multi-faceted solution to promote optimum development of premature infants.

Association of maternal breast milk and serum levels of macronutrients, hormones, and maternal body composition with infant's body weight

BACKGROUND/OBJECTIVES

This study was aimed to investigate the association of maternal serum and breast-milk levels of macronutrients, hormones, growth factors, and maternal body composition with infant's body weight.

SUBJECTS/METHODS

Eighty mother-infant pairs comprised 40 with overweight or obese infant and 40 with normal-weight infant were enrolled in this study. The level of ghrelin, Leptin, adiponectin, EGF, and IGF1 in plasma and breast milk were assessed. Daily breast milk intake and macronutrient concentration along with anthropometric indices of mother-infant pairs were also assessed.

RESULTS

No significant differences were observed in concentrations of serum hormones between two groups (p > 0.05). However, hormones levels in maternal serum were higher than those in breast milk. A significant positive correlation was found between serum EGF and ghrelin (r = 0.57, p = 0 < 0001). Higher IGF1 in serum showed a significant association with its milk counterpart (r = 0.37). Current mother's weight was associated with infant's weight at the 2nd and 6th month (B = 0.023 p = 0.04, B = 0.055 p = 0.005). The breast-milk macronutrient content was not comparable between two groups. However, the average daily breast milk consumption in obese infants was higher than normals (p = 0.001). Milk EGF and leptin were related to a decrease of 59% and 46% the odds of obese infant development, respectively. There was a significant association of milk EGF and ghrelin with birth weight (B = -0.19, p = 0.04 and B = -0.2, p = 0.04, respectively), and also serum leptin with infant's body weight at the 6th month.

CONCLUSIONS

Our findings provide a positive association of maternal weight, daily breast milk intake, EGF, and ghrelin with infant's body weight.

Protective effects of amniotic fluid in the setting of necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is the most common life threatening condition affecting preterm infants. NEC occurs in 1-5% of all neonatal intensive care admissions and 5-10% of very low birth weight infants. The protective role of human breast milk (BM) has been well established. It has also been shown that amniotic fluid (AF) and BM have many similarities in terms of presence of growth and other immune-modulatory factors. This finding led to the initial hypothesis that AF may exert similar protective effects against the development of NEC, as does BM. Multiple studies have elucidated the presence of growth factors in AF and the protective effect of AF against NEC. Studies have also described possible mechanisms how AF protects against NEC. At present, research in this particular area is extremely active and robust. This review summarizes the various studies looking at the protective effects of AF against the development of NEC. It also provides an insight into future directions, the vast potential of AF as a readily available biologic medium, and the ethical barriers that must be overcome before using AF.

Maintaining good miRNAs in the body keeps the doctor away?: Perspectives on the relationship between food-derived natural products and microRNAs in relation to exosomes/extracellular vesicles

During the last decade, it has been uncovered that microRNAs (miRNAs), a class of small non-coding RNAs, are related to many diseases including cancers. With an increase in reports describing the dysregulation of miRNAs in various tumor types, it has become abundantly clear that miRNAs play significant roles in the formation and progression of cancers. Intriguingly, miRNAs are present in body fluids because they are packed in exosomes/extracellular vesicles and released from all types of cells. The miRNAs in the fluids are measured in a relatively simple way and the profile of miRNAs is likely to be an indicator of health condition. In recent years, various studies have demonstrated that some naturally occurring compounds can control tumor-suppressive and oncogenic miRNAs in a positive manner, suggesting that food-derived compounds could maintain the expression levels of miRNAs and help maintain good health. Therefore, our daily food and compounds in food are of great interest. In addition, exogenous diet-derived miRNAs have been indicated to function in the regulation of target mammalian transcripts in the body. These findings highlight the possibility of diet for good health through the regulation of miRNAs, and we also discuss the perspective of food application and health promotion.

Innate Immunity and Breast Milk

Human milk is a dynamic source of nutrients and bioactive factors; unique in providing for the human infant's optimal growth and development. The growing infant's immune system has a number of developmental immune deficiencies placing the infant at increased risk of infection. This review focuses on how human milk directly contributes to the infant's innate immunity. Remarkable new findings clarify the multifunctional nature of human milk bioactive components. New research techniques have expanded our understanding of the potential for human milk's effect on the infant that will never be possible with milk formulas. Human milk microbiome directly shapes the infant's intestinal microbiome, while the human milk oligosaccharides drive the growth of these microbes within the gut. New techniques such as genomics, metabolomics, proteomics, and glycomics are being used to describe this symbiotic relationship. An expanded role for antimicrobial proteins/peptides within human milk in innate immune protection is described. The unique milieu of enhanced immune protection with diminished inflammation results from a complex interaction of anti-inflammatory and antioxidative factors provided by human milk to the intestine. New data support the concept of mucosal-associated lymphoid tissue and its contribution to the cellular content of human milk. Human milk stem cells (hMSCs) have recently been discovered. Their direct role in the infant for repair and regeneration is being investigated. The existence of these hMSCs could prove to be an easily harvested source of multilineage stem cells for the study of cancer and tissue regeneration. As the infant's gastrointestinal tract and immune system develop, there is a comparable transition in human milk over time to provide fewer immune factors and more calories and nutrients for growth. Each of these new findings opens the door to future studies of human milk and its effect on the innate immune system and the developing infant.

The Potential Impact of Animal Science Research on Global Maternal and Child Nutrition and Health: A Landscape Review

High among the challenges facing mankind as the world population rapidly expands toward 9 billion people by 2050 is the technological development and implementation of sustainable agriculture and food systems to supply abundant and wholesome nutrition. In many low-income societies, women and children are the most vulnerable to food insecurity, and it is unequivocal that quality nutrition during the first 1000 d of life postconception can be transformative in establishing a robust, lifelong developmental trajectory. With the desire to catalyze disruptive advancements in global maternal and child health, this landscape review was commissioned by the Bill & Melinda Gates Foundation to examine the nutritional and managerial practices used within the food-animal agricultural system that may have relevance to the challenges faced by global human health. The landscape was categorized into a framework spanning 1) preconception, 2) gestation and pregnancy, 3) lactation and suckling, and 4) postweaning and toddler phases. Twelve key findings are outlined, wherein research within the discipline of animal sciences stands to inform the global health community and in some cases identifies gaps in knowledge in which further research is merited. Notable among the findings were 1) the quantitative importance of essential fatty acid and amino acid nutrition in reproductive health, 2) the suggested application of the ideal protein concept for improving the amino acid nutrition of mothers and children, 3) the prospect of using dietary phytase to improve the bioavailability of trace minerals in plant and vegetable-based diets, and 4) nutritional interventions to mitigate environmental enteropathy. The desired outcome of this review was to identify potential interventions that may be worthy of consideration. Better appreciation of the close linkage between human health, medicine, and agriculture will identify opportunities that will enable faster and more efficient innovations in global maternal and child health.

Milk growth factors and expression of small intestinal growth factor receptors during the perinatal period in mice

BACKGROUND

Growth factors (GFs) are milk bioactive components contributing to the regulation of neonatal small intestinal maturation, and their receptors on the small intestinal epithelium play essential roles in mediating the functions of GFs. There is limited data correlating milk GFs and their receptors in the neonatal small intestine during the perinatal period.

METHODS

Small intestines of C57BL/6N mouse pups were collected at regular intervals during fetal life and up to postnatal day (PD) 60. Gene expression of GF receptors was determined by real-time qPCR. Milk GF concentrations up to PD21 were analyzed by enzyme-linked immunosorbent assay.

RESULTS

The majority of GF receptors showed significantly greater expression in the fetus than in postnatal life, and a sharp decrease occurred from PD14 extending to PD60; solid food restriction (PD14 and PD18) did not affect this decrease. Concentrations of five detected milk GFs demonstrated that GFs and the corresponding small intestinal receptors exhibited different correlations, with only milk transforming growth factor β1 (TGF-β1) having a significant positive correlation with TGF-β receptor 1 mRNA.

CONCLUSION

Gene expression of small intestinal GF receptors is likely a process of neonatal intestinal maturation that is affected concurrently by milk GFs and additional endogenous factors.

Amino Acid Composition of Breast Milk from Urban Chinese Mothers

Human breast milk (BM) amino acid (AA) composition may be impacted by lactation stage or factors related to geographical location. The present cross-sectional study is aimed at assessing the temporal changes of BMAA over lactation stages in a large cohort of urban mothers in China. Four hundred fifty BM samples, collected in three Chinese cities covering eight months of lactation were analyzed for free (FAA) and total (TAA) AA by o-phthalaldehyde/ fluorenylmethylchloroformate (OPA/FMOC) derivatization. Concentrations and changes over lactation were aligned with previous reports. Both the sum and the individual TAA values significantly decreased during the first periods of lactation and then generally leveled off. Leucine and methionine were respectively the most and the least abundant indispensable amino acids across all the lactation stages, whereas glutamic acid + glutamine (Glx) was the most and cystine the least abundant dispensable AA. The contribution of FAA to TAA levels was less than 2%, except for free Glx, which was the most abundant FAA. In conclusion, the AA composition of the milk from our cohort of urban Chinese mothers was comparable to previous studies conducted in other parts of the world, suggesting that this is an evolutionary conserved trait largely independent of geographical, ethnic, or dietary factors.

Delayed introduction of progressive enteral feeds to prevent necrotising enterocolitis in very low birth weight infants

BACKGROUND

The introduction of enteral feeds for very preterm (less than 32 weeks' gestation) or very low birth weight (VLBW; less than 1500 g) infants is often delayed for several days or longer after birth due to concern that early introduction may not be tolerated and may increase the risk of necrotising enterocolitis (NEC). However, delaying enteral feeding could diminish the functional adaptation of the gastrointestinal tract and prolong the need for parenteral nutrition with its attendant infectious and metabolic risks.

OBJECTIVES

To determine the effect of delayed introduction of progressive enteral feeds on the incidence of NEC, mortality and other morbidities in very preterm or VLBW infants.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, 2014, Issue 8), MEDLINE (1966 to September 2014), EMBASE (1980 to September 2014), CINAHL (1982 to September 2014), conference proceedings and previous reviews.

SELECTION CRITERIA

We included randomised or quasi-randomised controlled trials that assessed the effect of delayed (more than four days after birth) versus earlier introduction of progressive enteral feeds on the incidence of NEC, mortality and other morbidities in very preterm or VLBW infants.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility and risk of bias and undertook data extraction. We analysed the treatment effects in the individual trials and reported the risk ratio (RR) and risk difference for dichotomous data and mean difference for continuous data, with respective 95% confidence intervals (CI). We used a fixed-effect model in meta-analyses and explored the potential causes of heterogeneity in sensitivity analyses.

MAIN RESULTS

We identified nine randomised controlled trials in which 1106 infants participated. Few participants were extremely preterm (less 28 weeks' gestation) or extremely low birth weight (less than 1000 g). The trials defined delayed introduction of progressive enteral feeds as later than four to seven days after birth and early introduction as four days or less after birth. Meta-analyses did not detect statistically significant effects on the risk of NEC (typical RR 0.93, 95% CI 0.64 to 1.34; 8 trials; 1092 infants) or all-cause mortality (typical RR 1.18, 95% CI 0.75 to 1.88; 7 trials; 967 infants). Four of the trials restricted participation to growth-restricted infants with Doppler ultrasound evidence of abnormal fetal circulatory distribution or flow. Planned subgroup analyses of these trials found no statistically significant effects on the risk of NEC or all-cause mortality. Infants who had delayed introduction of enteral feeds took longer to establish full enteral feeding (reported median differences two to four days).

AUTHORS' CONCLUSIONS

The evidence available from randomised controlled trials suggested that delaying the introduction of progressive enteral feeds beyond four days after birth did not reduce the risk of developing NEC in very preterm or VLBW infants, including growth-restricted infants. Delaying the introduction of progressive enteral feeds resulted in a few days' delay in establishing full enteral feeds but the clinical importance of this effect was unclear. The applicability of these findings to extremely preterm or extremely low birth weight was uncertain. Further randomised controlled trials in this population may be warranted.

Predictors of full enteral feeding achievement in very low birth weight infants

BACKGROUND

To elucidate the role of prenatal, neonatal and early postnatal variables in influencing the achievement of full enteral feeding (FEF) in very low birth weight (VLBW) infants and to determine whether neonatal intensive care units (NICUs) differ in this outcome.

METHODS

Population-based retrospective cohort study using data on 1,864 VLBW infants drawn from the "Emilia-Romagna Perinatal Network" Registry from 2004 to 2009. The outcome of interest was time to FEF achievement. Eleven prenatal, neonatal and early postnatal variables and the study NICUs were selected as potential predictors of time to FEF. Parametric survival analysis was used to model time to FEF as a function of the predictors. Marginal effects were used to obtain adjusted estimates of median time to FEF for specific subgroups of infants.

RESULTS

Lower gestational age, exclusive formula feeding, higher CRIB II score, maternal hypertension, cesarean delivery, SGA and PDA predicted delayed FEF. NICUs proved to be heterogeneous in terms of FEF achievement. Newborns with PDA had a 4.2 days longer predicted median time to FEF compared to those without PDA; newborns exclusively formula-fed had a 1.4 days longer time to FEF compared to those fed human milk.

CONCLUSIONS

The results of our study suggest that time to FEF is influenced by clinical variables and NICU-specific practices. Knowledge of the variables associated with delayed/earlier FEF achievement could help in improving specific aspects of routine clinical management of VLBW infants and to reduce practice variability.

Time-dependent expression profiles of microRNAs and mRNAs in rat milk whey

Functional RNAs, such as microRNA (miRNA) and mRNA, are present in milk, but their roles are unknown. To clarify the roles of milk RNAs, further studies using experimental animals such as rats are needed. However, it is unclear whether rat milk also contains functional RNAs and what their time dependent expression profiles are. Thus, we prepared total RNA from whey isolated from rat milk collected on days 2, 9, and 16 postpartum and analyzed using microarrays and quantitative PCR. The concentration of RNA in colostrum whey (day 2) was markedly higher than that in mature milk whey (days 9 and 16). Microarray analysis detected 161 miRNAs and 10,948 mRNA transcripts. Most of the miRNAs and mRNA transcripts were common to all tested milks. Finally, we selected some immune- and development-related miRNAs and mRNAs, and analysed them by quantitative PCR (in equal sample volumes) to determine their time-dependent changes in expression in detail. Some were significantly more highly expressed in colostrum whey than in mature milk whey, but some were expressed equally. And mRNA expression levels of some cytokines and hormones did not reflect the protein levels. It is still unknown whether RNAs in milk play biological roles in neonates. However, our data will help guide future in vivo studies using experimental animals such as rats.

Managing and preventing outbreaks of Gram-negative infections in UK neonatal units

De novo guidance on the management of Gram-negative bacteria outbreaks in UK neonatal units was developed in 2012 by a Department of Health, England Antimicrobial Resistance and Healthcare Associated Infection working group. The recommendations included activation of an organisational response and establishing a control team when an outbreak is suspected; screening for the specific organism only during an outbreak; undertaking multidisciplinary reviews of cleaning routines, hand hygiene and Gram-negative bacteria transmission risks; considering deep-cleaning; cohorting colonised and infected babies preferably but not necessarily in isolation cubicles; and considering reducing beds or closing a unit to new admissions as a way of improving spacing and staff:patient ratios until the outbreak is under control. The group advised establishing mechanisms to communicate effectively across the network; informing parents of the outbreak as early as possible, and providing prewritten 'infection outbreak' information sheets. For prevention of outbreaks, the group advised meeting national staffing and cot-spacing requirements; following a Water Action Plan; using infection reduction care bundles and benchmarking; and introducing breast milk early and limiting antibiotic use.

Influence of L-threonine supplementation on goblet cell numbers, histological structure and antioxidant enzyme activities of laying hens reared in a hot and humid climate

1. A previous experiment in our laboratory found that L-threonine supplementation at 0.2 and 0.3% increased egg production and the concentration of serum IgG, respectively. The objective of this current trial was to determine if both supplementation levels can positively influence histological structure, goblet cell numbers, or antioxidant enzyme activities. 2. Babcock Brown layers (n=576), 40 weeks of age, were allocated to three treatment groups, each of which included 6 replicates of 32 hens. Each group received the same basal diet formulated with maize, peanut meal and crystalline amino acids. L-threonine was added to the basal diet at 0 (control), 0.2, and 0.3%, respectively for 8 weeks. Chemical analysis of the diets for threonine values were 0.47, 0.66 and 0.74 %, respectively. 3. The numbers of goblet cells did not change due to L-threonine supplementation. Also, L-threonine had no affect on the villus height and mucosal thickness. No differences were found due to treatments among groups in the activity of alkaline phosphatase (ALP) in jejunum or ileum. L-threonine supplementation at 0.2% maximised the concentration of superoxide dismutases (SOD) in both serum and liver. 4. In conclusion, L-threonine supplementation had no affect on gut morphology but may have an antioxidant function at 0.2%.

Delayed introduction of progressive enteral feeds to prevent necrotising enterocolitis in very low birth weight infants

BACKGROUND

The introduction of enteral feeds for very preterm (< 32 weeks) or very low birth weight (< 1500 g) infants is often delayed for several days or longer after birth due to concern that early introduction may not be tolerated and may increase the risk of necrotising enterocolitis (NEC). However, delaying enteral feeding could diminish the functional adaptation of the gastrointestinal tract and prolong the need for parenteral nutrition with its attendant infectious and metabolic risks.

OBJECTIVES

To determine the effect of delayed introduction of progressive enteral feeds on the incidence of necrotising enterocolitis, mortality and other morbidities in very preterm or very low birth weight infants.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, 2013, Issue 3), MEDLINE (1966 to April 2013), EMBASE (1980 to April 2013), CINAHL (1982 to April 2013), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that assessed the effect of delayed (more than four days after birth) versus earlier introduction of progressive enteral feeds on the incidence of NEC, mortality and other morbidities in very preterm or very low birth weight infants.

DATA COLLECTION AND ANALYSIS

We extracted data using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by two review authors.

MAIN RESULTS

We identified seven randomised controlled trials in which a total of 964 infants participated. Few participants were extremely preterm (< 28 weeks) or extremely low birth weight (< 1000 g). The trials defined delayed introduction as later than five to seven days after birth and early introduction as less than four days after birth. Meta-analyses did not detect statistically significant effects on the risk of NEC (typical risk ratio (RR) 0.92 (95% confidence interval (CI) 0.64 to 1.34) or all-cause mortality (typical RR 1.26 (95% CI 0.78 to 2.01)). Three of the trials restricted participation to growth-restricted infants with Doppler ultrasound evidence of abnormal fetal circulatory distribution or flow. Planned subgroup analyses of these trials did not find any statistically significant effects on the risk of NEC or all-cause mortality. Infants who had delayed introduction of enteral feeds took longer to establish full enteral feeding (reported median difference two to four days).

AUTHORS' CONCLUSIONS

The evidence available from randomised controlled trials suggests that delaying the introduction of progressive enteral feeds beyond four days after birth does not affect the risk of developing NEC in very preterm or very low birth weight infants, including growth-restricted infants. Delaying the introduction of progressive enteral feeds results in a few days delay in establishing full enteral feeds but the clinical importance of this effect is unclear. The applicability of these findings to extremely preterm or extremely low birth weight is uncertain. Further randomised controlled trials in this population may be warranted.

How to feed small for gestational age newborns

Feeding small for gestational age (SGA) newborns is extremely challenging and the neonatologist should be brave and cautious at the same time. Although these babies have a high risk of milk intolerance and necrotising enterocolitis, enteral feeding guidelines are not well established and practice varies widely among different neonatal units. Currently available studies on this topic include extremely and very low birth weight neonates, but are not focused specifically on small for gestational age infants. This review analyzes papers focused on feeding interventions in order to provide the best available evidences about the optimum timing for introduction of enteral feeding, how fast feed volume can be advanced, which milk and which feeding method is more appropriate in SGA infants.

Modulation of the intestinal environment, innate immune response, and barrier function by dietary threonine and purified fiber during a coccidiosis challenge in broiler chicks

Coccidiosis is a major contributor to economic losses in the poultry industry due to its detrimental effects on growth performance and nutrient utilization. We hypothesized that the combined effects of supplemental dietary Thr and purified fiber may modulate the intestinal environment and positively affect intestinal immune responses and barrier function in broiler chicks infected with Eimeria maxima. A Thr-deficient basal diet (3.1 g of Thr/kg of diet) was supplemented with 70 g/kg of silica sand (control) or high-methoxy pectin and 1 of 2 concentrations of Thr (1.8 or 5.3 g/kg of diet; 4 diets total), and fed to chicks from hatch to d 16 posthatch. On d 10 posthatch, chicks received 0.5 mL of distilled water or an acute dose of Eimeria maxima (1.5 × 10(3) sporulated oocytes) with 6 replicate pens of 6 chicks per each of 8 treatment combinations (4 diets and 2 inoculation states). Body weight gain, feed intake, and G:F increased (P < 0.01) with addition of 5.3 g of Thr/kg of diet. Eimeria maxima schizonts were present only in intestinal tissue sampled from infected birds (P < 0.01). Weights of cecal digesta were highest (P < 0.01) in pectin-fed birds, and ceca with the heaviest weights also had the highest concentrations of total short-chain fatty acids. Expression of interleukin-12 in ileal mucosa was highest (P < 0.01) in infected birds receiving the control diet with 5.3 g of supplemental Thr/kg. In cecal tonsils, interferon-γ expression was highest in infected birds receiving the control diet (fiber × infection, P < 0.05); interferon-γ expression was lowest in infected birds fed the high Thr diet (Thr × infection, P < 0.05). There were no differences due to infection or Thr supplementation for cytokine expression in birds fed pectin-containing treatments. Overall, we conclude that although pectin has some protective function against coccidiosis, Thr supplementation had the greatest effect on intestinal immune response and maintenance of near normal growth in young broiler chicks infected with E. maxima.

Bovine milk contains microRNA and messenger RNA that are stable under degradative conditions

We previously reported that microRNA (miRNA) is present in human breast milk. Recently, other groups have reported that bovine milk also contains miRNA; however, these reports are few. We therefore investigated bovine milk miRNA using microarray and quantitative PCR analyses to identify the differences between colostrum and mature milk. The RNA concentration in a colostrum whey fraction was higher than that in a mature milk whey fraction. In total, 102 miRNA were detected in bovine milk by microarray analysis (100 in colostrum and 53 in mature milk; 51 were common to both). Among these miRNA, we selected several immune- and development-related miRNA, including miR-15b, miR-27b, miR-34a, miR-106b, miR-130a, miR-155, and miR-223. These miRNA were detected in bovine milk by quantitative PCR, and each of these miRNA was significantly more highly expressed in colostrum than in mature milk. We also confirmed the presence of some mRNA in bovine milk. Nevertheless, synthesized miRNA spiked in the raw milk whey were degraded, and naturally existing miRNA and mRNA in raw milk were resistant to acidic conditions and RNase treatment. The RNA molecules in milk were stable. We also detected miRNA and mRNA in infant formulas purchased from Japanese markets. It is still unknown whether milk-derived RNA molecules play biological roles in infants; however, if milk-derived RNA do show functions in infants, our data will help guide future studies.

Nutritional factors influencing intestinal health of the neonate

Dietary nutrients are essential for gastrointestinal (GI) growth and function, and nutritional support of GI growth and development is a significant component of infant care. For healthy full-term neonates, nutritional provisions of the mother's milk and/or formula will support normal maturation of structure and function of the GI tract in most infants. The composition of breast milk affects GI barrier function and development of a competent mucosal immune system. The functional nutrients and other bioactive components of milk support a microenvironment for gut protection and maturation. However, premature infants struggle with feeding tolerance impairing normal GI function, leading to intestinal dysfunction and even death. The high prevalence worldwide of enteric diseases and dysfunction in neonates has led to much interest in understanding the role of nutrients and food components in the establishment and maintenance of a functioning GI tract. Neonates who do not receive enteral feeding as either mother's milk or formula are supported by total parental nutrition (TPN). The lack of enteral nutrition can compound intestinal dysfunction, leading to high morbidity and mortality in intestinally compromised infants. Reciprocally, enteral stimulation of an immature GI tract can also compound intestinal dysfunction. Therefore, further understanding of nutrient interactions with the mucosa is necessary to define nutritional requirements of the developing GI tract to minimize intestinal complications and infant morbidity. Piglet models of intestinal development and function are similar to humans, and this review summarizes recent findings regarding nutrient requirements for growth and maintenance of intestinal health. In particular, this article reviews the role of specific amino acids (arginine, glutamine, glutamate, and threonine), fatty acids (long chain polyunsaturated, medium chain, and short chain), various prebiotic carbohydrates (short-chain fructo-oligosaccharide, fructo--oligosaccharide, lacto-N-neotetraose, human milk oligosaccharide, polydextrose, and galacto-oligosaccharide), and probiotics that have been examined in the suckling piglet model of intestinal health.

Effects of dietary nucleotide supplementation on growth performance and hormonal and immune responses of piglets

The effects of dietary nucleotide supplementation from 9 days of age until the end of post-weaning on piglets hormonal and immune responses and on growth performance were investigated. During lactation (days 9 to 21) and post-weaning (days 22 to 55) 10 [HBI Fomeva11 × (Large White × Landrace)] litters (n = 108 piglets) had ad libitum access to two standard diets, both supplemented with 0% (T0 group) or 0.1% (T1 group) of yeast extract nucleotides. BW of piglets at days 21 (P < 0.10), 35 and 55 (P < 0.05) was greater in T1 compared with T0. Feed intake was not different between groups (P > 0.05). Cortisol content was lower in T1 than in T0 at days 28 and 35 (P < 0.05), whereas growth hormone was lower at day 35 (P < 0.05). Levels of IGF-1 were similar across groups (P > 0.05). Nucleotide-supplemented diets increased lymphocyte subpopulation CD4-CD8+high at days 21 and 35 (P < 0.05), whereas CD4+CD8- cells were higher in T1 than in T0 at day 21 (P < 0.05). Peripheral blood mononuclear cells cytokine expression was influenced by dietary nucleotide supplementation. At weaning, interleukin (IL)-6 and IL-1β expression was lower (P < 0.05) in T1 compared with T0, whereas the expression of interferon (IFN)-γ and IL-10 was higher (P < 0.05). At day 28, piglets in T1 showed higher values of tumor necrosis factor (TNF)-α expression than T0 and lower values of IL-10 expression (P < 0.05). Dietary nucleotide supplementation had a suppressive effect on IL-6 and IL-10 expression (P < 0.05) at day 35. On the contrary, the expression of IFN-γ, TNF-α and IL-1β was enhanced (P < 0.05). In conclusion, these results suggest that starting a dietary nucleotide supplementation before weaning can improve the adaptive capabilities of weaned piglets to the stressors, enhancing the growth performance.

Lactocrine programming of female reproductive tract development: environmental connections to the reproductive continuum

For eutherian mammals a continuum of maternal support insures that development of progeny follows an optimal program. Beginning in utero, such support extends into the early neonatal period when bioactive factors are communicated from mother to offspring in colostrum/milk. Defined as lactocrine signaling, communication of milk-borne bioactive factors from mother to offspring as a consequence of nursing is important for development of somatic tissues, including the female reproductive tract (FRT). Data for the domestic pig indicate that lactocrine signaling contributes to the maternal continuum of factors that define the developmental program and determine the developmental trajectory of FRT tissues during early neonatal life. Both naturally occurring and manmade factors of environmental origin can be communicated to neonates in milk and affect development with lasting consequences. Here, evidence for lactocrine programming of FRT development and the potential for environmental endocrine disruption of this process are reviewed.

In the critically ill, nothing-by-mouth infant, would enteral administration of simulated amniotic fluid improve feeding tolerance compared with the current practice of no therapy? An evidence-based review

Necrotizing enterocolitis (NEC ) can be a devastating disease in the NIC U population. The current standard of practice of not providing enteral nutrition to the critically ill and the premature infant is thought to result in pathophysiologic changes of the gastrointestinal (GI) tract that may result in the development of NEC. Various methods of preventing or reducing the incidence of NEC in the NIC U have been explored. One such method is the enteral administration of simulated amniotic fluid (SAF). This article compares, contrasts, and reviews the available evidence regarding the use of SAF feedings as a means of reducing GI tract changes associated with nothing-by-mouth (NPO) status.

Delayed introduction of progressive enteral feeds to prevent necrotising enterocolitis in very low birth weight infants

BACKGROUND

The introduction of progressive enteral feeds for very low birth weight (VLBW) infants is often delayed for several days or longer after birth due to concern that earlier introduction may not be tolerated and may increase the risk of necrotising enterocolitis (NEC). However, delaying enteral feeding could diminish the functional adaptation of the gastrointestinal tract and prolong the need for parenteral nutrition with its attendant infectious and metabolic risks.

OBJECTIVES

To determine the effect of delayed introduction of progressive enteral feeds on the incidence of NEC, mortality and other morbidities in VLBW infants.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, 2010, Issue 4), MEDLINE (1966 to December 2010), EMBASE (1980 to December 2010), CINAHL (1982 to December 2010), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that assessed the effect of delayed (more than four days' postnatal age) versus earlier introduction of progressive enteral feeds on the incidence of NEC, mortality and other morbidities in VLBW infants.

DATA COLLECTION AND ANALYSIS

Data collection and analysis were performed in accordance with the standard methods of the Cochrane Neonatal Review Group.

MAIN RESULTS

We identified five randomised controlled trials (RCT) in which a total of 600 infants participated. The trials defined delayed introduction as later than five to seven days after birth and early introduction as less than four days after birth. Two of the trials, in which a total of 488 infants participated, only recruited growth-restricted infants with Doppler ultrasound evidence of abnormal fetal circulatory distribution or flow. Meta-analyses did not detect statistically significant effects on the risk of NEC [typical relative risk 0.89, 95% confidence interval (CI) 0.58 to 1.37] or all cause mortality (typical relative risk 0.93, 95% CI 0.53 to 1.64). Infants who had delayed introduction of enteral feeds took significantly longer to establish full enteral feeding (reported median difference three days).

AUTHORS' CONCLUSIONS

Current trial data do not provide evidence that delayed introduction of progressive enteral feeds reduces the risk of NEC in VLBW infants. Delaying the introducing of progressive enteral feeds results in several days delay in establishing full enteral feeds but the clinical importance of this effect is unclear. Further RCTs are needed to give more precise estimates of the effect of delaying the introduction of enteral feeds on clinical outcomes in VLBW infants.

Nutritional modulation of the gut microbiota and immune system in preterm neonates susceptible to necrotizing enterocolitis

The gastrointestinal inflammatory disorder, necrotizing enterocolitis (NEC), is among the most serious diseases for preterm neonates. Nutritional, microbiological and immunological dysfunctions all play a role in disease progression but the relationship among these determinants is not understood. The preterm gut is very sensitive to enteral feeding which may either promote gut adaptation and health, or induce gut dysfunction, bacterial overgrowth and inflammation. Uncontrolled inflammatory reactions may be initiated by maldigestion and impaired mucosal protection, leading to bacterial overgrowth and excessive nutrient fermentation. Tumor necrosis factor alpha, toll-like receptors and heat-shock proteins are identified among the immunological components of the early mucosal dysfunction. It remains difficult, however, to distinguish the early initiators of NEC from the later consequences of the disease pathology. To elucidate the mechanisms and identify clinical interventions, animal models showing spontaneous NEC development after preterm birth coupled with different forms of feeding may help. In this review, we summarize the literature and some recent results from studies on preterm pigs on the nutritional, microbial and immunological interactions during the early feeding-induced mucosal dysfunction and later NEC development. We show that introduction of suboptimal enteral formula diets, coupled with parenteral nutrition, predispose to disease, while advancing amounts of mother's milk from birth (particularly colostrum) protects against disease. Hence, the transition from parenteral to enteral nutrition shortly after birth plays a pivotal role to secure gut growth, digestive maturation and an appropriate response to bacterial colonization in the sensitive gut of preterm neonates.

Intestinal mucin dynamics: response of broiler chicks and White Pekin ducklings to dietary threonine

Mucin dynamics may be particularly sensitive to a Thr deficiency due to the high concentration and structural importance of Thr in the mucin protein backbone. Intestinal mucin secretion, expression of mucin gene (MUC2), and histological characteristics were investigated in male broilers and White Pekin ducklings offered diets containing 3.3, 5.8, or 8.2 g of Thr/kg in 4 studies. Seventy-two birds of each species were fed a standard broiler starter diet from 1 to 14 d of age followed by assignment to 3 dietary treatments in a randomized complete block design for a 7-d feeding trial in experiment 1 (broilers) and experiment 2 (ducklings). The dietary treatments consisted of an isonitrogenous corn-soybean meal-based diet with the addition of crystalline amino acids and graded levels of Thr. Dietary treatments contained 3.3, 5.8, or 8.2 g of Thr/kg. Dietary formulation and experimental design for experiments 3 (broilers) and 4 (ducklings) were similar to experiments 1 and 2 except that birds were fed 3.3 or 8.2 g of Thr/kg for durations of 7 or 14 d. For chicks, increased dietary Thr resulted in higher levels of intestinal crude mucin excretion in experiment 1 (P=0.04) but not in experiment 3, whereas intestinal sialic acid excretion increased in experiment 3 (P=0.02) but not in experiment 1. Furthermore, there was no effect of Thr on intestinal goblet cell density or MUC2 mRNA abundance for broilers. For ducklings, there was an increase in intestinal crude mucin excretion in both experiments (P<0.05) as dietary Thr increased, although there was no effect of Thr on intestinal sialic acid excretion. There was a tendency for an increase in intestinal goblet cell density (cells/microm of villus length; P=0.09) as dietary Thr increased in experiment 2. For experiment 4, intestinal MUC2 mRNA abundance increased (P=0.03) as dietary Thr increased for the 14-d feeding trial but not for the 7-d feeding trial. The data establish a link between dietary Thr and intestinal crude mucin dynamics in chicks for experiment 1 and ducklings for both experiments.

Enteral glutamine and/or arginine supplementation have favorable effects on oxidative stress parameters in neonatal rat intestine

OBJECTIVE

To investigate and compare the effects of enteral glutamine and arginine supply on lipid peroxidation and antioxidant enzyme levels in the small intestine of healthy breast-fed rats.

MATERIALS AND METHODS

The study comprised 40 newborn Sprague-Dawley rats born to 5 mother rats. Newborn rats were randomly divided into 4 groups. Starting from day 1 until day 21, group I received only breast milk; group II received breast milk and 200 mg/kg/day oral glutamine; group III received breast milk and 200 mg/kg/day oral arginine; and group IV received breast milk, 200 mg/kg/day glutamine, and 200 mg/kg/day arginine. Malondialdehyde levels and glutathione peroxidase (GPx) and superoxide dismutase activities were measured.

RESULTS

The lowest malondialdehyde levels were found in group II (P = 0.0001). Superoxide dismutase activity was found to be significantly higher in group II than group I (P < 0.001). Of the 4 groups, GPx activity was highest in group IV. GPx activity in group II was significantly higher than in group I (P = 0.001) or group III (P = 0.001). GPx activity was higher in group IV than in group I (P = 0.001) or group III (P = 0.001).

CONCLUSIONS

Enteral glutamine alone or in the presence of arginine has favorable effects on oxidative stress not only in experimental models of hypoxia-reoxygenation, but also in healthy newborn rats. This suggests that in premature neonates with insufficient oxidative resistance, glutamine and arginine supplementation may help prevent necrotizing enterocolitis.

alpha-Lactalbumin hydrolysate stimulates glucagon-like peptide-2 secretion and small intestinal growth in suckling rats

We investigated whether bovine milk constituents influenced glucagon-like peptide (GLP)-2 secretion and intestinal growth in suckling rats. Male Sprague-Dawley rats (14 d old) received i.g. infusions of a milk protein fraction, a lactose solution, or the cream fraction of milk. The serum concentration of GLP-2, but not GLP-1, markedly increased in rats administered milk protein compared with those given the lactose solution or the cream fraction from 60 to 120 min after administration. In another experiment, both casein (CN) and whey protein isolate stimulated GLP-2 secretion at 120 min after administration, but soy protein and ovalbumin did not. Stimulation of GLP-2 secretion by several milk proteins was similar, including alpha-CN, alpha-lactalbumin (alpha-La), and beta-lactoglobulin, in a separate experiment. A hydrolysate of alpha-La obtained by incubation with protease A extracted from Aspergillus oryzae (LaHPA) caused almost twice the GLP-2 release due to intact alpha-La and other alpha-La hydrolysates. Free amino acid concentrations and molecular size distributions did not differ among alpha-La hydrolysates, including LaHPA. In rat pups reared with milk formulae containing alpha-La or LaHPA, LaHPA significantly promoted small intestinal elongation and increased the number of crypt epithelial cells compared with a formula containing intact alpha-La. LaHPA administration also increased the maltase:lactase activity ratio, a marker of maturation of the intestinal mucosa. In conclusion, milk proteins stimulate GLP-2 secretion and contribute to growth and maturation of the small intestine in suckling rats.

The Source and Secretion of Immunoactive Relaxin in Rat Milk

The milk of many mammalian species contains hormones and growth factors in addition to nutrients and immuocompetent substances. These factors can be absorbed into the circulation of suckling neonates to exert important effects on metabolism and promote tissue and organ growth. Frequently, there is uncertainty as to whether such substances are gene products of the mammary glands themselves or are produced elsewhere and concentrated from the systemic circulation. The 6 kD polypeptide, relaxin, appears in milk of several mammalian species, including that of the rat, but proof of its source of secretion (corpus luteum vs. mammary gland) is so far lacking. The specific monoclonal anti-rat relaxin antibody MCA1 has previously been utilized successfully to investigate many of relaxin’s actions in the rat, including those affecting the development of the mammary apparatus. In this report, MCA1 was utilized to aid in the identification of the source of relaxin in rat milk. Treatment of lactating rats with MCA1 completely neutralized the luteal relaxin circulating in serum but did not decrease the concentration of immunoactive relaxin secreted in milk. Moreover, the antibody did not appear to reach the mammary epithelium. The evidence thus supports the view that in the rat, the relaxin secreted in milk is primarily a product of the mammary glands and not concentrated from the systemic circulation.

Neonatal outcome of gastroschisis is mainly influenced by nutritional management

OBJECTIVE

The aim of the study was to evaluate early minimal enteral feeding (MEF) and gradual enteral nutrition increment on neonatal outcome of gastroschisis.

PATIENTS AND METHODS

An intervention group was prospectively assessed and compared with an observational historical control group. The prospective study relied on a new protocol of enteral nutrition. According to the new protocol, MEF was initiated 5 days after bowel reintegration and milk amounts were increased 12 mL/kg/day. In the control group, enteral nutrition was delayed until resolution of postoperative ileus, and increment of feeding was not systematized.

RESULTS

Twenty-two patients were included in the MEF group and compared with 51 control patients. Infants in the control group had lower gestational age (36 vs 35 gestational weeks [GW], P=0.03) and birth weight (2465 vs 2200 g, P=0.05). Time to first enteral nutrition (5 vs 11.5 days, P=0.0005) was significantly shorter in the MEF group. All patients in this group were fully enteral fed at day 60, though 30.4% of patients in the control group still needed parenteral nutrition at day 60 (P=0.004). Incidence of nosocomial infection was reduced (9% of patients vs 40%, P=0.016) and hospital stay tended to be shorter in the MEF group (40 vs 54.5 days, P=0.08). In the univariate analysis, factors influencing the length of parenteral nutrition during the 2 periods were the severity of perivisceritis and new nutritional protocol. In the multivariate analysis, only nutritional protocol was significantly associated with the length of parenteral nutrition (P=0.038).

CONCLUSIONS

Early MEF and controlled increase of nutritional elements after bowel reintegration significantly improved outcome of gastroschisis in newborns.

Animal models to study neonatal nutrition in humans

PURPOSE OF REVIEW

The impact of neonatal nutrition on the health status of the newborn and incidence of disease in later life is a topic of intense interest. Animal models are an invaluable tool to identify mechanisms that mediate the effect of nutrition on neonatal development and metabolic function. This review highlights recently developed animal models that are being used to study neonatal human nutrition.

RECENT FINDINGS

In recent years, mice, rats, and pigs have become the most frequently used animal models to study human neonatal nutrition. Techniques for rearing newborn mice, preterm rats, and preterm pigs have been developed. Neonatal mice have great potential for mechanistic and genomic research in postnatal nutrition and related diseases. The neonatal pig model is valuable to study acute and chronic effects of parenteral and enteral nutrition on whole-body metabolism as well as specific tissues. To date, a wealth of information from studies with neonatal pigs has been applied to humans.

SUMMARY

Further development of neonatal animal models related to nutrition is required for the advancement of research in early postnatal nutrition. Improvement of nutritional support during this critical period of development will enhance immediate clinical outcomes and possibly prevent diseases later in life.

Delayed introduction of progressive enteral feeds to prevent necrotising enterocolitis in very low birth weight infants

BACKGROUND

The introduction of progressive enteral feeds for very low birth weight infants is often delayed for several days or longer after birth due to concern that earlier introduction may not be tolerated and may increase the risk of necrotising enterocolitis. However, delaying enteral feeding could diminish the functional adaptation of the gastrointestinal tract and prolong the need for parenteral nutrition with its attendant infectious and metabolic risks.

OBJECTIVES

To determine the effect of delayed introduction of progressive enteral feeds on the incidence of necrotising enterocolitis, mortality and other morbidities in very low birth weight infants.

SEARCH STRATEGY

The standard search strategy of the Cochrane Neonatal Group was used. Searches were made of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 4, 2007), MEDLINE (1966 - December 2007), EMBASE (1980 - December 2007), CINAHL (1982- December 2007), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that assessed the effect of delayed (after 96 hours' postnatal age) versus earlier introduction of progressive enteral feeds on the incidence of necrotising enterocolitis, mortality and other morbidities in very low birth weight infants.

DATA COLLECTION AND ANALYSIS

The standard methods of the Cochrane Neonatal Group were used, with separate evaluation of trial quality and data extraction by two authors. Data were synthesised using a fixed effects model and reported using typical relative risk, typical risk difference and weighted mean difference.

MAIN RESULTS

Two small trials in which a total of 74 infants participated were eligible for inclusion. Only a minority of participants were of extremely low birth weight or extreme preterm gestation. These trials provided no evidence that delayed introduction of progressive enteral feeds affected the incidence of necrotising enterocolitis, mortality or other neonatal morbidities. However, in view of the small number of participants, important beneficial or harmful effects cannot be excluded.

AUTHORS' CONCLUSIONS

The available data are insufficient to inform clinical practice. Further large pragmatic randomised controlled trials are needed to determine how the timing of the introduction of progressive enteral feeds affects important clinical outcomes in very low birth weight infants, and particularly in extremely low birth weight or growth restricted infants.

Nutritional immunomodulation of acute pancreatitis

Despite the great advances in our understanding of the pathophysiology of acute pancreatitis, no specific therapy has emerged, and treatment remains supportive. In patients with the severe form of the disease, in which mortality remains high at 20% to 30%, the function of the upper gastrointestinal tract is disturbed due to extrinsic compression by the inflamed and swollen pancreas, and normal eating is impossible. Such patients often develop multiple organ failure, necessitating intensive-care management and artificial ventilation for weeks on end. In this setting, protein catabolism will rapidly result in protein deficiency and further complications unless nutritional support is commenced. Recent studies have shown that, despite the risk of disease exacerbation through pancreatic stimulation, enteral feeding is more effective than parenteral feeding in improving outcome. Experimental studies suggest that this can be attributed to its content of specific immunomodulating nutrients, such as glutamine, arginine, and n-3 fatty acids, and by its stabilizing effect on the gut flora through the provision of prebiotics. Further studies are indicated to examine whether dietary enrichment with these substrates, along with regulation of the gut bacteria with probiotics, can improve outcome further.