Breast milk is better than formula milk in preventing parenteral nutrition-associated liver disease in infants receiving prolonged parenteral nutrition

Gut Bifidobacterium longum is associated with better native liver survival in patients with biliary atresia

Background & Aims

The gut microbiome plays an important role in liver diseases, but its specific impact on biliary atresia (BA) remains to be explored. We aimed to investigate the microbial signature in the early life of patients with BA and to analyze its influence on long-term outcomes.

Methods

Fecal samples (n = 42) were collected from infants with BA before and after Kasai portoenterostomy (KPE). The stool microbiota was analyzed using 16S rRNA next-generation sequencing and compared with that of age-matched healthy controls (HCs). Shotgun metagenomic sequencing analysis was employed to confirm the bacterial composition in 10 fecal samples before KPE. The correlation of the microbiome signature with liver function and long-term outcomes was assessed.

Results

In the 16S rRNA next-generation sequencing analysis of fecal microbiota, the alpha and beta diversity analyses revealed significant differences between HCs and patients with BA before and after KPE. The difference in microbial composition analyzed by linear discriminant analysis and random forest classification revealed that the abundance of Bifidobacterium longum (B. longum) was significantly lower in patients before and after KPE than in HCs. The abundance of B. longum was negatively correlated with the gamma-glutamyltransferase level after KPE (p <0.05). Patients with early detectable B. longum had significantly lower total and direct bilirubin 3 months after KPE (p <0.005) and had a significantly lower liver transplantation rate (hazard ratio: 0.16, 95% CI 0.03-0.83, p = 0.029). Shotgun metagenomic sequencing also revealed that patients with BA and detectable B. longum had reduced total and direct bilirubin after KPE.

Conclusion

The gut microbiome of patients with BA differed from that of HCs, with a notable abundance of B. longum in early infancy correlating with better long-term outcomes.

Impact and implications

Bifidobacterium longum (B. longum) is a beneficial bacterium commonly found in the human gut. It has been studied for its potential impacts on various health conditions. In patients with biliary atresia, we found that a greater abundance of B. longum in the fecal microbiome is associated with improved clinical outcomes. This suggests that early colonization and increasing B. longum levels in the gut could be a therapeutic strategy to improve the prognosis of patients with biliary atresia.

Dilemmas in establishing preterm enteral feeding: where do we start and how fast do we go?

Beginning and achieving full enteral nutrition is a key step in the care of preterm infants, particularly very low birth weight (VLBW) infants. As is true for many organ system-specific complications of prematurity, the gastrointestinal tract must complete in utero development ex utero while concurrently serving a physiologic role reserved for after completion of full term development. The preterm gut must assume the placental function of the interface between a source of energy, precursors for anabolism, and micronutrients, and the developing infant-through digestion and absorption of milk, instead of directly from the mother via the uteroplacental interface. The benefits of enteral nourishment in preterm infants are counterbalanced by gastrointestinal complications of prematurity: dysmotility leading to difficulty establishing and advancing feeds, and the risk of necrotizing enterocolitis (NEC). Concern for these complications can prolong the need for parenteral nutrition with an associated increase in risk for central line-associated bloodstream infection (CLABSI) and parenteral nutrition (PN)-associated cholestasis or liver disease (PNALD). Thus, a daily issue facing neonatologists caring for preterm infants is how to optimally begin, advance, and reach full enteral nutrition sufficient to satisfy the nutrient, energy, and fluid requirements of VLBW infants while minimizing risk. In this perspective, we provide an overview of the approaches and supporting data for starting and advancing enteral feeds in preterm infants, particularly very low birth weight infants, and we discuss the significant gaps in knowledge that accompany current approaches. This framework recognizes the dilemmas of preterm feeding initiation and advancement and identifies areas of opportunity for further investigation.

Nutrition and Intestinal Rehabilitation of Children With Short Bowel Syndrome: A Position Paper of the ESPGHAN Committee on Nutrition. Part 1: From Intestinal Resection to Home Discharge

Short bowel syndrome (SBS) is the leading cause of intestinal failure (IF) in children. The mainstay of treatment for IF is parenteral nutrition (PN). The aim of this position paper is to review the available evidence on managing SBS and to provide practical guidance to clinicians dealing with this condition. All members of the Nutrition Committee of the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) contributed to this position paper. Some renowned experts in the field joined the team to guide with their experience. A systematic literature search was performed from 2005 to May 2021 using PubMed, MEDLINE, and Cochrane Database of Systematic Reviews. In the absence of evidence, recommendations reflect the expert opinion of the authors. Literature on SBS mainly consists of retrospective single-center experience, thus most of the current papers and recommendations are based on expert opinion. All recommendations were voted on by the expert panel and reached >90% agreement. The first part of this position paper focuses on the physiological mechanism of intestinal adaptation after surgical resection. It subsequently provides some clinical practice recommendations for the primary management of children with SBS from surgical resection until discharged home on PN.

Intestinal adaptation and rehabilitation

Massive intestinal resection is a regrettably necessary but life-saving intervention for progressive or fulminant necrotizing enterocolitis (NEC). However, the resultant short bowel syndrome (SBS) poses its own array of challenges and complications. Within hours of such an abrupt loss of intestinal length, the intestine begins to adapt. Our ability to understand this process of intestinal adaptation has proven critical in our ability to clinically treat the challenging problem of short bowel syndrome. This review first highlights key data relating to intestinal adaptation including structural and functional changes, biochemical regulation, and other factors affecting the magnitude of intestinal adaptation responses. We then focus on intestinal rehabilitation as it relates to strategies to enhance intestinal adaptation while meeting nutritional needs and preventing complications of parenteral nutrition.

An Overview of Short-Bowel Syndrome in Pediatric Patients: Focus on Clinical Management and Prevention of Complications

Short-bowel syndrome (SBS) in pediatric age is defined as a malabsorptive state, resulting from congenital malformations, significant small intestine surgical resection or disease-associated loss of absorption. SBS is the leading cause of intestinal failure in children and the underlying cause in 50% of patients on home parental nutrition. It is a life-altering and life-threatening disease due to the inability of the residual intestinal function to maintain nutritional homeostasis of protein, fluid, electrolyte or micronutrient without parenteral or enteral supplementation. The use of parenteral nutrition (PN) has improved medical care in SBS, decreasing mortality and improving the overall prognosis. However, the long-term use of PN is associated with the incidence of many complications, including liver disease and catheter-associated malfunction and bloodstream infections (CRBSIs). This manuscript is a narrative review of the current available evidence on the management of SBS in the pediatric population, focusing on prognostic factors and outcome. The literature review showed that in recent years, the standardization of management has demonstrated to improve the quality of life in these complex patients. Moreover, the development of knowledge in clinical practice has led to a reduction in mortality and morbidity. Diagnostic and therapeutic decisions should be made by a multidisciplinary team that includes neonatologists, pediatric surgeons, gastroenterologists, pediatricians, nutritionists and nurses. A significant improvement in prognosis can occur through the careful monitoring of nutritional status, avoiding dependence on PN and favoring an early introduction of enteral nutrition, and through the prevention, diagnosis and aggressive treatment of CRSBIs and SIBO. Multicenter initiatives, such as research consortium or data registries, are mandatory in order to personalize the management of these patients, improve their quality of life and reduce the cost of care.

State of the Science on the Benefits of Human Milk for Hospitalized, Vulnerable Neonates

Research on human milk has increased dramatically in recent years. The purpose of this review is to describe the literature on the health benefits of human milk for hospitalized, vulnerable neonates. PubMed, CINAHL, and Embase were searched for research articles reporting the health outcomes of hospitalized neonates who were exposed to human milk. Human milk, particularly a mother's own milk, has the potential to reduce the risk of death and the risk and severity of necrotizing enterocolitis, infection, retinopathy of prematurity, bronchopulmonary dysplasia, intraventricular hemorrhage, kidney disease, and liver disease. Dose and timing of human milk is important, with more human milk and earlier introduction having a greater impact on health. When a mother's own milk is not available, donor human milk provides benefits over infant formula.

Distinct Gut Microbiome Induced by Different Feeding Regimes in Weaned Piglets

It is well accepted that the gut microbiota of breast-fed (BF) and formula-fed (FF) infants are significantly different. However, there is still a limited number of studies comparing the gut microbiota of BF and FF piglets, despite increasing numbers of FF piglets in the modern pig industry. The present study identified the differences in gut microbiota composition between BF- and FF-weaned Rongchang piglets at 30 days old, using pair-end sequencing on the Illumina HiSeq 2500 platform. The BF piglets had lower microbiota diversities than FF piglets (p < 0.05), and the community structures were well clustered as a result of each feeding pattern. Firmicutes and Bacteroidetes represented the most dominant phyla, and Ruminococcus, Prevotella, and Gemmiger were prominent genera in all piglets. Ruminococcus, Prevotella, Oscillospira, Eubacterium, Gemmiger, Dorea, and Lactobacillus populations were significantly higher, while Treponema and Coprococcus were significantly lower in BF piglets compared to FF piglets (p < 0.05). The metabolism pathways in the BF piglets were significantly different from FF piglets, which included carbohydrate and amino acid metabolism (p < 0.05). In addition, the top 10 abundance of microbiota were more or less significantly associated with the two phenotypes (p < 0.05). Collectively, these findings provide probable explanations for the importance of BF in neonates and support a theoretical basis for feeding regimes in indigenous Chinese piglets.

Current strategies for managing intestinal failure-associated liver disease

Introduction: Intestinal failure-associated liver disease (IFALD) refers to hepatic dysfunction that results from prolonged parenteral nutrition (PN) use. IFALD is multifactorial in origin and remains a major cause of morbidity and mortality. Prior to 2004, IFALD was associated with mortality as high as 90% in infants who remained on PN greater than 1 year. The advent of new strategies for intravenous lipid emulsion (ILE) administration and improved catheter care now allow many patients to remain on PN and recover from this once fatal condition. Several additional treatment modalities are often used to further improve outcomes for IFALD patients and they are reviewed here.Areas covered: The etiology of IFALD is presented, as well as the rationale behind the use of ILEs that contain fish oil. Other management strategies are addressed, including the effects of several pharmacologic and nutritional interventions.Expert opinion: Like its etiology, the management of IFALD is multifactorial. Prompt recognition of patients at risk, avoiding macronutrient excess, and preventing central line associated bloodstream infections will improve outcomes. In patients who develop IFALD, the use of fish oil monotherapy seems to be efficacious. The most effective intervention, however, continues to be discontinuation of PN and achieving full enteral feedings.

Intestinal failure in adults and children

Intestinal failure (IF) is rare, but it represents one of the most complex medical-surgical management pathologies, both in adults and children. The first-line treatment is parenteral nutrition (PN). However, new alternatives in the field of intestinal rehabilitation have opened up in recent decades, with the rise of multidisciplinary teams and the development of new hormone therapies as the first non-symptomatic approach to IF.

Supplementation of Mother's Own Milk with Donor Milk in Infants with Gastroschisis or Intestinal Atresia: A Retrospective Study

BACKGROUND

Mother's own milk (MOM) improves in-hospital outcomes for preterm infants. If unavailable, donor milk (DM) is often substituted. It is unclear if DM vs. formula to supplement MOM is associated with improved in-hospital outcomes in term/late preterm surgical infants with gastroschisis or intestinal atresia.

METHODS

This retrospective study included infants born ≥33 weeks gestational age (GA) with a birth weight of >1500 g who were admitted to a quaternary neonatal intensive care unit (NICU). Using Chi square and Mann-Whitney u testing, we compared hospital outcomes (length of stay, parenteral nutrition and central line days) before and after a clinical practice change to offer DM instead of formula in this surgical population.

RESULTS

Baseline characteristics were similar between eras for the 140 infants (median GA 37 weeks). Fewer infants in DM era were receiving formula at discharge (50.0% vs. 31.4%, p = 0.03). In sub-analyses including only small bowel atresia and gastroschisis infants, the median length of stay (35 vs. 25, p < 0.01) and the central line days (28 vs. 20, p < 0.01) were lower in the DM era.

CONCLUSION

In this retrospective study, offering DM instead of formula was associated with less formula feeding at discharge, and in infants with gastroschisis or small bowel atresia, shorter length of stay and central line days.

Evaluation of parenteral nutrition-associated liver disease in surgical infants for necrotizing enterocolitis

The purpose of this study was to determine the factors associated with parenteral nutrition-associated liver disease (PNALD) in infants who underwent surgery for necrotizing enterocolitis (NEC) and followed up the postoperative outcomes for long term parenteral nutrition (PN).This study included a retrospective review of 87 infants with NEC and managed surgically from July 2007 to May 2017 at the Children's Hospital, Chongqing Medical University. Clinical data and procedure information were collected and analyzed.Among the infants included, 16.1% of patients developed PNALD. Multivariable logistic regression analysis revealed progressive clinical deterioration (OR, 5.47; 95% CI, 1.10-26.96; P = .037) was independent risk factor for PNALD whereas congenital heart disease (OR, 0.068; 95% CI, 0.008-0.55; P = .012) presentation served as a protective factor.The current data suggested the distinct disease process for cardiac patients with NEC, which might help in the prevention and treatment of PNALD for patients with NEC.

Short Bowel Syndrome

Purpose of Review

Short gut syndrome is life-altering and life-threatening disease resulting most often from massive small bowel resection. Recent advances in understanding of the perturbed physiology in these patients have translated into improved care and outcomes. This paper seeks to review the advances of care in SBS patients.

Recent Findings

Anatomic considerations still predominate the early care of SBS patients, including aggressive preservation of bowel and documentation of remnant bowel length and quality. Intestinal adaptation is the process by which remnant bowel changes to fit the physiologic needs of the patient. Grossly, the bowel dilates and elongates to increase intestinal weight and protein content. Architectural changes are noted, such as villus lengthening and deepening of crypts. In addition, gene expression changes occur that function to maximize nutrient uptake and fluid preservation. Management is aimed at understanding these physiologic changes and augmenting them whenever possible in an effort to gain enteral autonomy. Complication mitigation is key, including avoidance of catheter complications, bloodstream infections, cholestasis, and nutrient deficiencies.

Summary

Multidisciplinary teams working together towards intestinal rehabilitation have shown improved outcomes. Today's practioner needs a current understanding of the ever-evolving care of these patients in order to promote enteral autonomy, recognize complications, and counsel patients and families appropriately.

Prevention and Treatment of Intestinal Failure-Associated Liver Disease in Children

Intestinal failure-associated liver disease (IFALD) is a threatening complication for children on long-term parenteral nutrition because of intestinal failure. When progressive and intractable, it may jeopardize intestinal rehabilitation and lead to combined liver and intestinal transplantation. The institution of dedicated intestinal failure centers has dramatically decreased the incidence of such complication. IFALD may rapidly fade away if very early management aimed at preventing progression to end-stage liver disease is provided. In this review, we address the etiology and risk factors of IFALD in order to introduce pillars of prevention (nutritional management and catheter-related infections control). The latest evidence of therapeutic strategies, such as medical and surgical treatments, is also discussed.

Management of short bowel syndrome in postoperative very low birth weight infants

Short bowel syndrome is a potentially devastating morbidity for the very low birth weight infant and family with a high risk for mortality. Prevention of injury to the intestine is the ideal, but, if and when the problem arises, it is important to have a systematic approach to manage nutrition, use pharmaceutical strategies and tools to maximize the outcome potential. Safely maximizing parenteral nutrition support by providing adequate macronutrients and micronutrients while minimizing its hepatotoxic effects is the initial postoperative strategy. As the infant stabilizes and starts to recover from that initial injury and/or surgery, a slow and closely monitored enteral nutrition approach should be initiated. Enteral feeds can be complemented with medications and supplements emerging as valuable clinical tools. Engaging a multidisciplinary team of neonatologists, gastroenterologists, pharmacists, skilled clinical nutrition support staff including registered dietitians and nutrition support nurses will facilitate optimizing each and every infant's long term result. Promoting intestinal rehabilitation and adaptation through evidence-based practice where it is found, and ongoing pursuit of research in this rare and devastating disease, is paramount in achieving optimal outcomes.

Assessment of Aflatoxin M1 and Heavy Metal Levels in Mothers Breast Milk in Famagusta, Cyprus

Breast milk contributes towards optimal nutrition for infants. However, studies showed that it can also contain different toxins and heavy metals, which reduce its health benefits. The aim of this study is to determine the level of contaminants such as aflatoxin M1 (AFM1), Pb, Cd, As, and Hg in breast milk samples from Famagusta, Cyprus. Correlations between moldy food consumption, smoking habits of the mothers, and contaminant levels in breast milk were also investigated. Breast milk samples from 50 lactating mothers in rural and urban areas of Famagusta District were analyzed for AFM1 by ELISA. Eighty percent of them were found to be contaminated with AFM1 with the mean measurement of 7.84 ± 1.72 ng/l. Socio-demographic status, moldy food consumption habits, and smoking status do not have any effect on the AFM1 levels observed in breast milk. Heavy metal levels in breast milk were examined by inductively coupled plasma mass spectrometry, and the mean measurements were1.19 ± 1.53 ppm for Pb, 0.73 ± 0.58 ppm for As, 0 ± 0.20 ppm for Hg, and 0.45 ± 0.23 ppm for Cd. This study indicates that the levels of these contaminants in breast milk samples obtained in Famagusta District are well within the acceptable levels. However, the presence of AFM1 and heavy metals still may pose risks for infant health.

Effects of a Breast Milk Diet on Enteral Feeding Outcomes of Neonates with Gastrointestinal Disorders

OBJECTIVE

The objective of this study was to assess whether a diet of ≥50% breast milk (BM) was associated with earlier transition off parenteral nutrition (PN) in neonates with gastrointestinal (GI) disorders.

METHODS

This retrospective study assessed enteral feeding outcomes of neonates with surgical GI disorders admitted within the first week of life to a single center between January 1, 2012 and August 10, 2015. Outcomes were assessed according to diet from the point of first enteral intake through 7 days of full enteral feeds. Diets were classified as 100%, ≥50%, or <50% BM.

RESULTS

One hundred sixty-three patients with an average gestational age of 36 weeks (range 28-40) and birthweight of 2570 g (range 1250-4900) were included. Significant differences in days to full enteral feeds between the 100% and <50% BM groups were found (median 21 versus 32 days; p = 0.023). There were no significant differences between the 100% and ≥50% BM (p = 0.05) or ≥50% versus <50% BM groups (p = 0.74). The 100% BM group had significantly fewer days on PN compared to the ≥50% BM group (median 21 versus 28.5 days, p = 0.034). Hospital length of stay was significantly shorter in the 100% BM group, which was discharged an average of 10 and 13.5 days sooner than the ≥50% and <50% BM groups (p < 0.05).

CONCLUSIONS

Neonates with specific GI disorders who received a 100% BM diet were found to achieve earlier full enteral feeds, have shorter PN courses, and be discharged from the hospital significantly sooner than those who received diets that included formula.