Mineral requirements of low-birth-weight infants

Efficient CO2 fixation into cyclic carbonates catalyzed by NNO-scorpionate zinc complexes

Chiral bifunctional and bicomponent NNO-scorpionate zinc-based catalysts have been developed for the fixation of CO₂ into cyclic carbonates with broad substrate scope and functional group tolerance under mild and solvent-free conditions.

Ring-opening copolymerisation of cyclohexene oxide and carbon dioxide catalysed by scorpionate zinc complexes

New bimetallic heteroscorpionate zinc complexes have been developed and used as efficient catalysts for the synthesis of poly(cyclohexene carbonate).

Effect of supplementation of preterm formula with long chain polyunsaturated Fatty acids on mineral balance in preterm infants

BACKGROUND

Incorporation of long chain polyunsaturated fatty acids (LCP) into formulas may interfere with mineral metabolism. We investigate mineral balance in preterm infants who were fed a formula with LCP.

METHODS

Infants were randomized in a double-blind manner, 20 infants in each group, to receive a formula with LCP (F+LCP) or without LCP (F) for 30 days. Plasma levels (at the beginning and after 30 days) and nutritional balance (after 1 week) for Ca, P, Mg, Zn, and Cu were obtained for all infants.

RESULTS

Groups were similar regarding birth weight, gestational age, weight, and corrected age at study start. During the 30-day study period, the groups had comparable milk intake and reached similar and satisfactory weight gains and longitudinal growth. Within each group, there was no change in plasma mineral concentrations over the course of the study, and there were no differences at each time point between groups. All values were within the normal range for age. No differences in mineral balance were detected between the F and F+LCP groups, with both groups demonstrating comparable intake, net retention, and fecal losses of each mineral.

CONCLUSIONS

Adding a content of LCP blend similar to that of human milk to a preterm formula caused no disturbance in Ca, P, Mg, Zn, or Cu nutritional balance.

Metabolic bone disease in very-low-birth-weight infants: assessment, prevention, and treatment by neonatal nurse practitioners

OBJECTIVE

To describe the current practice of neonatal nurse practitioners in assessing skeletal health and preventing and treating metabolic bone disease in very-low-birth-weight infants.

DESIGN

Descriptive, retrospective survey.

PARTICIPANTS

Neonatal nurse practitioners in the continental United States were systematically randomly selected. A 64% response rate was obtained (112).

MAIN OUTCOME MEASURES

Responses to questions about assessing skeletal health and preventing and treating metabolic bone disease in very-low-birth-weight infants.

RESULTS

Current practice of neonatal nurse practitioners includes assessing skeletal health of very-low-birth-weight infants on the 7th (47.3%) or 14th (19.6%) day of life, with subsequent assessments every 7 (63.3%) or 14 (18.8%) days. Neonatal nurse practitioners (85.1%) estimate the incidence of metabolic bone disease at less than 15%. Neonatal nurse practitioners initiate total parenteral nutrition (99%), provide parenteral calcium and phosphorous in ratios of 1.3-1.7:1 (9%), and add powdered fortifier (90.1%) and liquid fortifier (25.2%) to expressed breast milk. All respondents use formulas made for premature infants. Physical therapy is used by 46.8% of neonatal nurse practitioners.

CONCLUSIONS

Neonatal nurse practitioners underestimate the incidence of metabolic bone disease. Parenteral calcium and phosphorous are given but in quantities that differ from the recommended ratio. Most neonatal nurse practitioners use formulas made for premature infants and add powdered fortifier to expressed breast milk. Although physical therapy is prescribed, more research on its effect on bone mineralization is warranted before this practice is recommended without reservation.

Casein phosphopeptides improve zinc and calcium absorption from rice-based but not from whole-grain infant cereal

BACKGROUND

Casein phosphopeptides (CPP) are phosphorus-rich peptide fragments of casein, assumed to contribute to the high bioavailability of calcium from milk.

METHODS

The effect of casein phosphopeptides on calcium and zinc absorption from infant foods was investigated. Twenty-two men and women were given single test meals extrinsically labeled with Ca and Zn. Absorption was calculated from measurements on whole-body retention of the radioisotopes. Each subject was given either rice-based cereal (n = 11) or whole-grain cereal (n = 11) on three occasions together with 250 ml water and added 0, 1, and 2 g CPP in random order. One serving of rice-based cereal contained 481 mg Ca and 1.29 mg Zn; whole-grain cereal contained 541 mg Ca and 1.77 mg Zn. One and 2 g of CPP contributed with additional 69 and 138 mg Ca, respectively.

RESULTS

From rice-based cereal, fractional calcium absorption was not affected by CPP addition (mean +/- SD): 16.0 +/- 4.0% (no CPP), 17.6 +/- 4.5% (1 g CPP), and 15.8 +/- 4.3% (2 g CPP), while the total quantity of calcium absorbed was significantly improved: 7 +/- 19 mg, 97 +/- 25 mg, and 98 +/- 26 mg, respectively (p = 0.0004). Fractional zinc absorption as well as total quantity of zinc absorbed were increased with addition of CPP: 19.4 +/- 9.0% (0.25 +/- 0.12 mg), 25.2 +/- 7.5% (0.33 +/- 0.10 mg) and 23.9 +/- 5.4% (0.31 +/- 0.07 mg) at the three CPP levels (p = 0.04). From whole-grain cereal, CPP had no effect on the percentage or actual quantity of calcium absorbed: 17.0 +/- 3.2% (92 +/- 18 mg), 17.2 +/- 4.5% (105 +/- 27 mg), and 15.0 +/- 4.6% (102 +/- 31 mg), respectively. Zinc absorption was also not influenced by CPP: 16.0 +/- 5.1% (0.28 +/- 0.09 mg), 15.3 +/- 3.1% (0.27 +/- 0.06 mg) and 18.1 +/- 4.4% (0.32 +/- 0.08 mg), respectively.

CONCLUSIONS

CPP addition improved calcium and zinc absorption from rice-based cereal, while no effect was seen from whole-grain cereal.

Metabolic bone disease of prematurity

Metabolic bone disease is recognized with increasing frequency in very-low-birth-weight infants. Radiological changes characteristic of rickets have been found in 55% of infants with a birth weight of less than 1000 g and in 23% of infants weighing less than 1500 g at birth. Twenty-four per cent of infants with a birth weight of less than 1500 g have fractures. The main aetiological factor is insufficient phosphorus supplementation. The aetiology is, however, multifactorial and also includes calcium deficiency, vitamin D deficiency, certain drugs, aluminium loading and immobilisation. The method of choice in detecting subclinical mineral bone disease of prematurity is measurement of bone mineral density, but there is as yet no single good diagnostic method available for premature infants. The optimal mineral and vitamin D requirement of the premature infant must be established so that proper recommendations can be given. The current recommended vitamin D dose in Europe (ESPGAN 800-1000 IU/day) is probably too high when extra minerals are supplied. Moreover, the duration of mineral supplementation may need to be continued until the infant has reached a body weight of 3.5 kg. This article deals with the aetiology, pathogenesis, diagnosis and future prospects of metabolic bone disease of prematurity.

Calcium, phosphorus and magnesium needs for the low-birth-weight infant

Parental mineral-containing solutions for LBW infants should be started soon after birth. For the initiation of parenteral nutrition and during short-term therapy for less than 2 weeks' duration, LBW infants should receive parenteral nutrition solutions at rates of approximately 120-130 ml/kg/day, containing minerals at the following concentrations: Ca 15 mM, P 15 mM and Mg 2.5 mM. For optimal growth and nutrient utilization, however, LBW infants maintained on parenteral nutrition at rates of 120-130 ml/kg/day for 2 or more weeks should receive mineral concentrations of Ca 20 mM, P 20 mM and Mg 2.5 mM. In addition, these latter mixtures must contain amino acids in concentrations greater than or equal to 2.2 g% and cysteine-HCl must be provided. As newer formulations emerge, these recommendations may be modified. For human milk-fed LBW infants, after 1 week of enteral feeding, Ca and P should be supplied as fortifiers. Ca 2-3 mmol/kg/day and P 1.5-2.0 mmol/kg/day should be provided in addition to human milk. Magnesium supplementation of human milk is unnecessary. These recommendations assume that the intake of human milk is approximately 200 ml/kg/day and will decrease as more bioavailable mineral salts are found. For LBW infants fed commercial formula, the intake of Ca should be greater than 3.5 mmol/kg/day, P 2.5 mmol/kg/day and Mg 0.2 mmol/kg/day. These recommendations assume reported bioavailabilities of mineral salts. If more bioavailable sources are found, these recommendations will decrease.(ABSTRACT TRUNCATED AT 250 WORDS)

How appropriate are commercially available human milk fortifiers?

A preliminary investigation was made into the effectiveness of two breastmilk fortifiers on the Australian market (FM-85 [Nestlé, Vevey, Switzerland] and Enfamil Human Milk Fortifier [EHMF; Mead Johnson, Evansville, IN, USA]). Infants < 1800 g and < 34 weeks gestation at birth, who were receiving breast milk, were randomized to receive either of the fortifiers (n = 14 for FM-85, n = 10 for EHMF), until a weight of 2 kg was reached. Infants not receiving breast milk (n = 9) were fed a preterm formula (Prenan, Nestlé). The two fortifier groups were similar in most parameters examined: (i) weight gain (17.9 +/- 3.0 vs 17.4 +/- 3.5 g/kg per day); (ii) head circumference growth (1.02 +/- 0.28 vs 1.03 +/- 0.25 cm/week); (iii) arm muscle area growth (32.6 +/- 20.0 vs 33.5 +/- 13.7 mm2/week); (iv) arm fat area growth (14.0 +/- 8.7 mm2/week); (v) plasma calcium (2.52 +/- 0.08 vs 2.58 +/- 0.15 mmol/L); (vi) plasma phosphate (2.02 +/- 0.21 vs 2.13 +/- 0.32 mmol/L); (vii) plasma copper (5.28 +/- 2.83 vs 5.66 +/- 3.07 mumol/L); and (vii) plasma zinc (13.3 +/- 5.5 vs 15.8 +/- 9.2 mumol/L). The FM-85 group had a higher alkaline phosphatase level (355 +/- 110 vs 231 +/- 70 iu/L) than the EHMF group; however, no values were outside the normal range. The Prenan group had a higher rate of weight gain (23.6 +/- 3.3 g/kg per day) and higher arm fat area growth rate (25.2 +/- 7.6 mm2/week) than the fortifier groups while all other parameters were similar.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of parenteral calcium and phosphorus therapy on mineral retention and bone mineral content in very low birth weight infants

HYPOTHESIS

If calcium and phosphorus are administered to very low birth weight infants in amounts larger than those currently used in standard parenteral nutrition solutions, apparent retention of calcium and phosphorus (intake minus urinary excretion) will increase and bone mineralization will improve.

DESIGN

Randomized, controlled, double-blind trial.

SETTING

Neonatal intensive care unit.

PATIENTS

Twenty-four very low birth weight infants (< 1.2 kg) expected to receive parenteral nutrition exclusively for approximately 3 weeks beginning 3 days after birth.

INTERVENTIONS

Infants received parenteral nutrition solutions, either the standard mixture containing 1.25 mmol calcium and 1.5 mmol phosphorus per deciliter (group STAND: n = 12, birth weight 921 +/- 171 gm, gestational age 27 +/- 2 weeks (mean +/- SD)) or 1.7 mmol calcium and 2.0 mmol phosphorus per deciliter (group HIGH: n = 12, 857 +/- 180 gm, 27 +/- 2 weeks).

MAIN OUTCOME MEASURES

Intake, urinary excretion, and apparent retention of calcium, phosphorus, and magnesium every 3 days during parenteral nutrition therapy. Serum indexes of mineral status twice during therapy. Bone mineral content of the distal segment of the left radius at 1, 4, 8, and 26 weeks.

RESULTS

Apparent calcium retention (1.2 +/- 0.2 vs 1.6 +/- 0.2 mmol.kg-1.d-1) and phosphorus retention (1.4 +/- 0.2 vs 1.8 +/- 0.4 mmol.kg-1.d-1) differed significantly (p < 0.01) between groups STAND and HIGH, respectively; neither changed with the duration of parenteral nutrition therapy. Serum calcium, magnesium, parathyroid hormone, 25-hydroxyvitamin D, and osteocalcin concentrations were similar in both groups. Serum phosphorus concentration was significantly higher in group HIGH than in group STAND (p = 0.025). The absolute bone mineral content and the rate of increase in bone mineral content between 1 and 4, 1 and 8, and 1 and 26 weeks were significantly greater in group HIGH than in group STAND.

CONCLUSIONS

Increased parenteral intakes of calcium and phosphorus resulted in greater retention of these minerals during parenteral nutrition therapy and in greater bone mineral content after therapy.

Parenteral nutrition-related bone disease

Parenteral nutrition (PN)-related bone disease remains a problem in patients of all ages. Understanding of the pathogenesis of PN-related bone disease is complicated by the effect of underlying illnesses, therapeutic interventions, and pre-existing nutrition deficiencies before the initiation of PN therapy. Interrelation of various nutrients, for example, calcium, phosphorus, and vitamin D, in their effects on bone mineralization, demands simultaneous assessment of the role of multiple nutrients and increases the difficulty in defining the role of a single nutrient in the development of bone disease. However, recent reports indicate that there exist a number of factors important in the development of PN-related bone disease and some factors such as increased mineral requirement are unique to growing infants whereas other factors such as aluminum toxicity may be common to both adult and pediatric populations. Nonnutritional factors, including chronic use of potent loop diuretics and altered acid-base status, can affect urine mineral loss, cell metabolism, and bone mineralization, particularly in small, preterm infants. Current evidence indicates that the cause of PN-related bone disease is multifactorial, and the prevention of PN-related bone disease awaits better delineation of the exact sequence of pathogenic events.