Can lactoferrin prevent neonatal sepsis and necrotizing enterocolitis?

The application of lactoferrin in infant formula: The past, present and future

Human milk is universally regarded as the gold standard to fulfill nutrition needs of infants. Lactoferrin (LF) is a major multiple bioactive glycoprotein in human milk but little is presented in infant formula. LF can resist digestion in the infant gastrointestinal tract and is absorbed into the bloodstream in an intact form to perform physiological functions. Evidence suggest that LF prevents pathogen infection, promotes immune system development, intestinal development, brain development and bone health, as well as ameliorates iron deficiency anemia. However, more clinical studies of LF need to be further elucidated to determine an appropriate dosage for application in infant formula. LF is sensitive to denaturation induced by processing of infant formula such as heat treatments and spay drying. Thus, further studies should be focus on maximizing the retention of LF activity in the infant formula process. This review summarizes the structural features of LF. Then the digestion, absorption and metabolism of LF in infants are discussed, followed by the function of LF for infants. Further, we summarize LF in infant formula and effects of processing of infant formula on bioactivities of LF, as well as future perspectives of LF research.

[Clinical guidelines for the diagnosis and treatment of neonatal necrotizing enterocolitis (2020)]

Necrotizing enterocolitis (NEC) is a devastating gastrointestinal disease of neonates, especially of preterm infants, with high morbidity and mortality. The surviving infants may have digestive tract and neurological sequelae. Therefore, the prevention and treatment of NEC are of great significance in improving survival rate and survival quality of neonates. To provide evidence-based recommendations for management of NEC, the guidelines were developed based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and the current domestic and overseas studies.

Protocol for the Lactoferrin Infant Feeding Trial (LIFT): a randomised trial of adding lactoferrin to the feeds of very-low birthweight babies prior to hospital discharge

INTRODUCTION

Very-low birthweight (VLBW, <1500 g) infants comprise about 1%-1.4% of all births in high-income countries. Every year, about 3000 VLBW babies in Australia and New Zealand receive intensive care. Many die or else survive with severe brain injury, retinopathy, late-onset sepsis or necrotising enterocolitis (NEC), each of which carries substantial risk of disability.

METHODS AND ANALYSIS

This trial tests whether adding bovine lactoferrin (bLF) to feeds in VLBW infants improves (1) survival to hospital discharge free from brain injury, late-onset sepsis, NEC and treated retinopathy of prematurity (primary composite end point); (2) each component of the primary composite end point and (3) time to reach full enteral feeds, number of blood transfusions, chronic lung disease and length of hospital stay. It includes a cost-effectiveness analysis of bLF in improving survival free from major morbidity, and evaluates the effect of bLF on survival and developmental outcomes at 24 to 36 months corrected gestational age.This is a multicentre, two-arm, randomised trial comparing the treatment group receiving bLF added to breast milk or formula milk daily (up to 250 mg/kg/day bLF) versus the control group receiving no bLF supplementation. The intervention is administered until 34 completed weeks corrected gestation or for 2 weeks, whichever is longer, or until discharge home, if earlier. The target sample size of 1500 participants yields 85% power, at the two-sided 5% level significance, to detect a difference in proportions meeting the primary outcome assuming the true probability is 74% in controls and 80.5% in the bLF group.

ETHICS AND DISSEMINATION

This protocol was approved by Northern Sydney Local Human Research Ethics Committee in January 2017 (Version 2.0, Reference 1003-118M) and other relevant ethics committees. The findings of the trial will be disseminated through peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

ACTRN12611000247976; Pre-results.

Comparison of lactoferrin activity in fresh and stored human milk

OBJECTIVE

Lactoferrin (Lf), the dominant protein in human milk (HM), has been shown to have anti-inflammatory and anti-microbial activity in the neonatal gut. Previous studies indicate that freezing significantly decreases the concentration of Lf in HM. The objective of our study was to compare the activity of Lf in fresh and frozen HM over time.

STUDY DESIGN

HM samples were examined fresh and after storage at -20 °C for 3 and 6 months. Lf concentration was determined by enzyme-linked immunoassay, and the activity was measured by examination of nitric oxide (NO) production and tumor necrosis factor-α secretion from rat macrophages exposed to HM samples.

RESULT

After 3 and 6 months at -20 °C, the average decrease in Lf concentrations was 55% and 65%, respectively. The bioactivity of Lf also decreased significantly over 6 months.

CONCLUSION

Freezing HM for 3 or more months significantly decreases Lf levels and activity. Periodically providing fresh HM may benefit vulnerable preterm neonates.

DoMINO: Donor milk for improved neurodevelopmental outcomes

BACKGROUND

Provision of mother's own milk is the optimal way to feed infants, including very low birth weight infants (VLBW, <1500 g). Importantly for VLBW infants, who are at elevated risk of neurologic sequelae, mother's own milk has been shown to enhance neurocognitive development. Unfortunately, the majority of mothers of VLBW infants are unable to provide an adequate supply of milk and thus supplementation with formula or donor milk is necessary. Given the association between mother's own milk and neurodevelopment, it is important to ascertain whether provision of human donor milk as a supplement may yield superior neurodevelopmental outcomes compared to formula.Our primary hypothesis is that VLBW infants fed pasteurized donor milk compared to preterm formula as a supplement to mother's own milk for 90 days or until hospital discharge, whichever comes first, will have an improved cognitive outcome as measured at 18 months corrected age on the Bayley Scales of Infant Development, 3(rd) ed. Secondary hypotheses are that the use of pasteurized donor milk will: (1) reduce a composite of death and serious morbidity; (2) support growth; and (3) improve language and motor development. Exploratory research questions include: Will use of pasteurized donor milk: (1) influence feeding tolerance and nutrient intake (2) have an acceptable cost effectiveness from a comprehensive societal perspective?

METHODS/DESIGN

DoMINO is a multi-centre, intent-to-treat, double blinded, randomized control trial. VLBW infants (n = 363) were randomized within four days of birth to either (1) pasteurized donor milk or (2) preterm formula whenever mother's own milk was unavailable. Study recruitment began in October 2010 and was completed in December 2012. The 90 day feeding intervention is complete and long-term follow-up is underway.

DISCUSSION

Preterm birth and its complications are a leading cause long-term morbidity among Canadian children. Strategies to mitigate this risk are urgently required. As mother's own milk has been shown to improve neurodevelopment, it is essential to ascertain whether pasteurized donor milk will confer the same advantage over formula without undue risks and at acceptable costs. Knowledge translation from this trial will be pivotal in setting donor milk policy in Canada and beyond.

TRIAL REGISTRATION

ISRCTN35317141; Registered 10 August 2010.

Necrotizing enterocolitis: the road to zero

Necrotizing enterocolitis (NEC) continues to be the most severe gastrointestinal emergency facing the preterm neonate. The pathogenesis of NEC is still a complex and poorly understood process, but with increasing understanding of the role of enteral feeding, gut immunity and the altered gut microbiota, new opportunities to reduce overall NEC rates are now possible. Prevention strategies continue to lead as the most suitable approaches to reducing NEC, as early diagnosis and rapid effective treatment of NEC are still not optimal. Programmatic changes are equally important as subscribing to individual prevention strategies. The primary focus of this review is to summarize the best strategies we currently have to eliminate NEC within an institution.

Pathophysiology and treatment of septic shock in neonates

Neonatal septic shock is a devastating condition associated with high morbidity and mortality. Definitions for the sepsis continuum and treatment algorithms specific for premature neonates are needed to improve studies of septic shock and assess benefit from clinical interventions. Unique features of the immature immune system and pathophysiologic responses to sepsis, particularly those of extremely preterm infants, necessitate that clinical trials consider them as a separate group. Keen clinical suspicion and knowledge of risk factors will help to identify those neonates at greatest risk for development of septic shock. Genomic and proteomic approaches, particularly those that use very small sample volumes, will increase our understanding of the pathophysiology and direct the development of novel agents for prevention and treatment of severe sepsis and shock in the neonate. Although at present antimicrobial therapy and supportive care remain the foundation of treatment, in the future immunomodulatory agents are likely to improve outcomes for this vulnerable population.