Effect of Fortification of Breast Milk in Conjugation with Protein Supplement on Neurodevelopment of Preterm Low Birth Weight Infants at 3 Years

Nutrient trajectories during infancy and their associations with childhood neurodevelopment

PURPOSE

To examine the associations between infants' dietary nutrient trajectories and subsequent neurodevelopment during childhood in the Growing Up in Singapore Towards healthy Outcomes study.

METHODS

One-day food records were collected at ages 6, 9 and 12 months, whilst Bayley Scales of Infant and Toddler Development-III and Kaufman Brief Intelligence Test-2 were conducted at ages 24 and 54 months respectively. Nutrient trajectories were constructed using multi-level mixed modelling and associations with neurodevelopment (24 months: n = 484; 54 months: n = 444) were examined using adjusted multivariable linear regression.

RESULTS

At age 24 months, higher protein intake (at 6 months) and increasing rate of intake (from 6 to 12 months) were associated with higher fine motor score [β = 0.17 SD (95% CI 0.03, 0.31) and 0.62 SD (0.10, 1.14) respectively]. Higher fat intake was associated with higher receptive language score [0.04 SD (0.003, 0.07)], but increasing rate of intake was associated with lower expressive language [- 0.20 SD (- 0.39, - 0.01)] and fine motor [- 0.29 SD (- 0.48, - 0.10)] scores. Higher carbohydrate intake was associated with lower gross motor score [- 0.07 SD (- 0.14, - 0.005)], but increasing rate of intake was associated with higher receptive language [0.44 SD (0.08, 0.81)] and fine motor [0.56 SD (0.18, 0.93)] scores. Increasing rate of dietary fibre intake was associated with higher fine motor scores [0.63 SD (0.16, 1.10)]. No significant associations were observed with neurodevelopment at 54 months.

CONCLUSION

Our findings provide greater understanding of how nutrition over time could have varying effects on child neurodevelopment.

Using Nature to Nurture: Breast Milk Analysis and Fortification to Improve Growth and Neurodevelopmental Outcomes in Preterm Infants

Premature infants are born prior to a critical window of rapid placental nutrient transfer and fetal growth-particularly brain development-that occurs during the third trimester of pregnancy. Subsequently, a large proportion of preterm neonates experience extrauterine growth failure and associated neurodevelopmental impairments. Human milk (maternal or donor breast milk) is the recommended source of enteral nutrition for preterm infants, but requires additional fortification of macronutrient, micronutrient, and energy content to meet the nutritional demands of the preterm infant in attempts at replicating in utero nutrient accretion and growth rates. Traditional standardized fortification practices that add a fixed amount of multicomponent fortifier based on assumed breast milk composition do not take into account the considerable variations in breast milk content or individual neonatal metabolism. Emerging methods of individualized fortification-including targeted and adjusted fortification-show promise in improving postnatal growth and neurodevelopmental outcomes in preterm infants.

Preterm nutrition and neurodevelopmental outcomes

Survival of preterm infants has been steadily improving in recent years because of many recent advances in perinatal and neonatal medicine. Despite these advances, the growth of survivors does not reach the ideal target level of the normal fetus of the same gestational age. Postnatal weight gain is often not achieved because extrauterine growth has higher energy requirements than intrauterine growth, due to the intensive care environment, illness and inadequate nutrition. Although many other factors influence infant brain development, including family socioeconomic and educational background, the role of nutrition is considerable and fortunately, amenable to intervention. In the preterm neonate, the brain is the most metabolically demanding organ, consuming the largest proportions of energy and nutrient intake for its function and programmed growth and maturation. Weight gain, linear and head circumference growth are all markers of nutritional status and are independently associated with long-term neurodevelopment. Brain development is not only the result of nutrients intake, but in addition, of the interaction with growth factors which depend on adequate nutrient supply and overall health status. This explains why conditions such as sepsis, necrotizing enterocolitis and chronic lung disease alter the distribution and accretion of nutrients thereby suppressing growth factor synthesis. In this review, we will focus on the direct role of nutrition on neurodevelopment, emphasizing why it should be started without delay. The nutritional requirements of the preterm infant will be discussed, followed by the effects of general nutritional interventions and specific nutrients, as well as the role of nutritional supplements on neurodevelopment. The primordial role of human breast milk, breast milk fortifiers and human milk oligosaccharides will be discussed in detail. We will also examine the role of nutrition in preventing neonatal complications which can affect neurodevelopment in their own right.

Evaluation of Human Milk Quality during its Distribution Flow at Neonatal Assistance Units

Background:

Premature babies have physiological vulnerabilities that influence their absorption and digestion capacity, compromising their clinical condition. Human milk from human milk banks has contributed enormously to providing these newborns with complete nutrition.

Objective:

To evaluate the quality of human milk collected at the Human Milk Bank during its distribution in neonatal units.

Methods:

A cross-sectional study, with a quantitative approach, was carried out in a maternity hospital with Human Milk Bank. After the pasteurization of milk and its consequent release to these units, a new test was carried out for the analysis of acid titration, caloric and microbiological content.

Results:

Human Milk showed a decrease of approximately 20% in caloric content and a reduction in acidity. Approximately 12.3% of the samples were contaminated by fecal coliforms.

Conclusion:

There is a need for a second moment of evaluation of human milk, after the flow, or to rethink the new ways of preserving the initial quality of human milk.

The "Fortilat" Randomized Clinical Trial Follow-Up: Neurodevelopmental Outcome at 18 Months of Age

Adequate nutrition is fundamental to neonatal survival and short-term outcomes, but it also has long-term consequences on quality of life and neurologic development of preterm infants. Donkey milk has been suggested as a valid alternative for children allergic to cows’ milk proteins, due to its biochemical similarity to human milk; we, hence, hypothesized that donkey milk could be a suitable basis for developing an innovative human milk fortifier for feeding preterm infants. The aim of the current study was to extend the findings and to evaluate the neurodevelopmental outcomes at 18 months of corrected age of the infants enrolled in the clinical trial named “Fortilat”. Infants born ≤1500 g and <32 weeks of gestational age were randomized to receive either a combination of bovine milk-based multicomponent fortifier and protein supplement or a combination of a novel multicomponent fortifier and protein supplement derived from donkey milk. The followed fortification protocol was the same for the two groups and the two diets were designed to be isoproteic and isocaloric. All infants enrolled were included in a developmental assessment program. The neurodevelopmental assessment was performed at 18 ± 6 months of corrected age. Minor and major neurodevelopmental impairment and General Quotient (GQ) at the Griffiths-II Mental Development Scale were considered. The GQ was considered both in continuous and as two classes: lower than and higher than (or equal to) a defined cutoff (GQcl). The difference in GQ and GQcl between the two arms was estimated using Mann–Whitney–Wilcoxon test or Fischer exact test, respectively, on the assumption of casual loss at follow-up. A further analysis was performed using generalized linear models. There were 103 children (bovine milk-derived fortifier arm = 54, donkey milk-derived fortifier arm = 49) included for the neurodevelopmental follow-up. All observations were included in the interval of 18 ± 6 months of corrected age. No significant difference was observed between the two arms in the incidence of neurologic sequelae and the GQs were similar in the two arms. Our results demonstrated no difference for the donkey milk-derived fortifier compared to standard bovine-derived fortifier regarding long-term neurodevelopmental outcomes.

Effect of adding dexmedetomidine or remifentanil to thiopental in patients with mood disorder candidate for electroconvulsive therapy

Electroconvulsive therapy (ECT) is one of the appropriate treatments for many neuropsychiatric patients, especially those with mood disorders. Short-term complications of ECT include agitation and postictal. In this study, we compared the addition of dexmedetomidine or remifentanil to thiopental as the main anaesthetic used in ECT. In this double-blind randomised clinical trial, 90 patients with mood disorders (candidates for ECT) were divided into two groups based on their therapy: dexmedetomidine or remifentanil. In the first group (DG), patients were slowly injected intravenously with 0.5 μg/kg dexmedetomidine before induction of anesthesia. In the second group (GR), 100 μg of remifentanil was slowly injected intravenously.In addition, we collected demographic information such as respiratory rate, heart pulse rate, seizure time, mean of arterial blood pressure, recovery duration and the oxygen arterial saturation recorded after recovery. Data obtained were analysed by use of statistical software, SPSS-23. The mean age of both groups was approximately 37 years with the majority being men. There was no significant difference between the two groups in terms of age and sex, blood pressure, heart rate, duration of seizures and arterial oxygen saturation before ECT. The mean blood pressure and heart rate in the recovery group were lower in the dexmedetomidine group than in the remifentanil group and the hemodynamics in the dexmedetomidine group were more stable. The recovery time in the dexmedetomidine group was longer than that of the remifentanil group (p = 0.001). Both groups had approximately the same satisfaction and the rate of agitation after ECT was the same. Both remifentanil and dexmedetomidine as adjuvants lead to a decrease in patients' post-ECT hyperdynamic responses. In our study, we demonstrated that the effect of dexmedetomidine is greater than remifentanil. On the other hand, neither dexmedetomidine nor remifentanil had a negative effect on seizure duration, but dexmedetomidine significantly prolonged recovery time, when compared to remifentanil.

Nutritional status of trauma patients hospitalized at surgical intensive care unit

Malnutrition results from a decrease or increase or imbalance of energy, protein and other nutrients, leading to measurable negative effects on body tissue, body shape, organ function and clinical status. Research shows that nutritional support is one of the necessary processes for survival of traumatic patient hospitalized at surgical intensive care unit. The purpose of this study is to evaluate the nutritional status of trauma patients hospitalized at surgical intensive care unit of Kowsar Hospital in Semnan, Iran. This cross-sectional descriptive study was performed on patients older than 18 years with head, neck and femur injuries. Initial data were collected using a checklist containing demographic information questions, designed from the Ministry of Health and Medical Education's Nutrition Screening Form, which was available in the Nutrition Assessment Forms and Guidelines for Hospitalized Patients Approved in 2013. The data were analyzed using Chi-square or Fisher's exact tests, paired t-test and Pearson coefficient. The confidence level was 95% and significance level was less than 0.05 in all tests. The amount of energy determined by the intensive care unit for the patients, with a significantly lower relationship than the amount of energy required by the patients for 24 hours, based on the Harris Benedict formula was (918.20±474.80 calories vs. 1535.76±243.73 calories, respectively and P-value˂0.001). The amount of protein determined by the intensive care unit for the patients for 24 hours, with a significantly relationship lower than the protein required for the patients for 24 hours, was (51.68±34.39 vs. 106.57±13.67, respectively, and P-value˂ 0.001). There was a statistically significant relationship between the age of the patients and energy (P˂0.001) and protein (P˂0.001) determined by the intensive care unit for the patients for 24 hours and energy (P˂0.001) and protein (P˂0.001) required for the patients for 24 hours. The results of this study showed that both the amount of energy and the amount of protein determined by the intensive care unit for trauma patients for less than 24 hours were lower than the required level; therefore, dietary modification for these patients is recommended.

Pain in child patients: A review on managements

Pain has been known as one of the major universal health concerns about ill children, because of its morbidity and potential mortality. Pain suitable evaluation is a challenge in children because the verbalization is difficult. Low clinical information, few pediatric researches, and the worry of opioid side effects make difficult to provide satisfactory treatments. Many pharmacologic and non-pharmacologic strategies to manage pain exist for pediatric pain treatment. The purpose of this review article is to describe exhaustively pain mechanism, evaluation and management by review literature from January 2000 to January 2019 using PubMed, EMBASE, MEDLINE, LILACS databases. Pharmacological and integrative non-pharmacological therapies has been indicated in acute and chronic pain treatment. Opioids and opioid-sparing agents target nociceptive and neuropathic pain. With due attention to available results, an early combination of pharmacological and integrative non pharmacological treatments are indicated in children pain management.

Renal function in the third year among very low birth weight infants fed by supplemental proteins

Very Low Birth Weight (VLBW) infants have higher nutritional needs than term infants. Energy and protein are two important factors influencing their growth. Breastfeeding is not enough to meet VLBW infants' needs, for this reason, complementary protein is required by them. Hence, the present study aimed at investigation of renal function among VLBW infants receiving complementary proteins. The study was conducted on two groups of intervention and control (n= 18 in each group) (Case study: VLBW infants born in Akbarabadi hospital of Tehran in 2014 2015). The intervention group includes 3-year-old children who weighting less than 1200 grams at birth and have received protein supplementation at the course of NICU hospitalization, protein was added to maternal milk when the amount of milk reaches to 100 cc/kg/day, at this time parenteral nutrition was discontinued and the volume of feeding was increased 20cc/kg/day until reached to 150-180cc/kg/day. We also added the fortifier to breast milk at this time. The fortification and the protein supplementation were stopped when the weight of the baby reached to 1500 grams. The control group was fed similar to the intervention group but had received no complementary protein . The renal function was evaluated by measuring such criteria as BUN, Cr, ALB and U/A. After data collection, a statistical analysis was performed using SPSS software Ver. 22. Following to BUN evaluation, a significant correlation was seen between BUN and received protein (p-value=0.010). However, there was no significant correlation between Cr and received protein as well as mean values of the two groups (p-value=0.0766). Similarly, an insignificant correlation was found between the two groups following to investigation of ALB (p-value=0/257), while the mean values of the two groups were similar. The both groups were also equal in U/A. The complementary protein increased the BUN with no effect on Cr, ALB and U/A, providing no impact on renal function. Therefore, complementary protein intake made no conflict in renal function.

A randomized controlled trial on Aspirin and complex regional pain syndrome after radius fractures

Complex regional pain syndrome (CRPS) is often diagnosed in patients who are recovered with surgery or injury. CRPS is usually diagnosed in patients recovering from distal radius fractures. The aim of study was the effects of aspirin in prevention of the complex regional pain syndrome (CRPS) following a fracture of distal radius. In a double-blind, randomized controlled trial, 91 patients with unilateral extra-articular distal radius fractures were randomly allocated to receive either placebo (PLA) or 500 mg of aspirin (ASA) daily for 7 days. The effect of aspirin on the occurrence of CRPS was evaluated. The patients were assessed clinically and radiographically in the second, fourth and twelfth weeks by a physician who was unaware of the treatment allocation. Ninety-one patients (ASA, n=44; PLA, n=47) were enrolled in the study. The prevalence of CRPS in all patients was 16.5%. The prevalence of CRPS in the aspirin group was lower (13.6%) than the placebo group (19.1%), but this difference was not statistically significant. The only significant difference was the lower rate of regional osteoporosis seen in the radiographs of aspirin group. Mean age was significantly higher in the patients with CRPS. Also, comminuted distal radius fractures (A3-type) were significantly more common in the patients with CRPS. Administration of aspirin in patients with a distal radius fracture was associated with a lower incidence of CRPS, but, not statistically significant. Further investigations needs to be done with a larger sample size, longer follow-up period and multi-center design.

Investigation of the association between metabolic syndrome and breast cancer patients

One of the most serious cancers among women is breast cancer. This disease is the first reason for the death of women due to cancer. Increasing breast cancer risk may associate with many factors including genetic, reproductive factors, people's lifestyle, metabolic syndrome (MS) and hormones. MS has been known as a risk factor for prostate, pancreatic, breast and colorectal cancers. The purpose of this review is to identify the relationship between MS components and breast cancer individually. This study was performed by researching electronic database references including PubMed, Google Scholar, CINAHL ProQuest, and web of science through 2019. The effect of MS with its components and breast cancer was reported in many studies. Nevertheless, a thorough understanding of the mechanisms involved remains a challenge. However, one can take several preventive measures, including a proper diet, which is one of the most important determinants of metabolic status. Also, general preventive recommendations are including reducing alcohol consumption, red meat and total fat in the diet. Moreover, increasing the consumption of vegetable and fruit reduce the proportion of MS patients to improve the outcome of breast cancer patients.

Renal function in the third year among very low birth weight infants fed by supplemental proteins

Very Low Birth Weight (VLBW) infants have higher nutritional needs than term infants. Energy and protein are two important factors influencing their growth. Breastfeeding is not enough to meet VLBW infants’ needs, for this reason, complementary protein is required by them. Hence, the present study aimed at investigation of renal function among VLBW infants receiving complementary proteins. The study was conducted on two groups of intervention and control (n= 18 in each group) (Case study: VLBW infants born in Akbarabadi hospital of Tehran in 2014 2015). The intervention group includes 3-year-old children who weighting less than 1200 grams at birth and have received protein supplementation at the course of NICU hospitalization, protein was added to maternal milk when the amount of milk reaches to 100 cc/kg/day, at this time parenteral nutrition was discontinued and the volume of feeding was increased 20cc/kg/day until reached to 150-180cc/kg/day. We also added the fortifier to breast milk at this time. The fortification and the protein supplementation were stopped when the weight of the baby reached to 1500 grams. The control group was fed similar to the intervention group but had received no complementary protein . The renal function was evaluated by measuring such criteria as BUN, Cr, ALB and U/A. After data collection, a statistical analysis was performed using SPSS software Ver. 22. Following to BUN evaluation, a significant correlation was seen between BUN and received protein (p-value=0.010). However, there was no significant correlation between Cr and received protein as well as mean values of the two groups (p-value=0.0766). Similarly, an insignificant correlation was found between the two groups following to investigation of ALB (p-value=0/257), while the mean values of the two groups were similar. The both groups were also equal in U/A. The complementary protein increased the BUN with no effect on Cr, ALB and U/A, providing no impact on renal function. Therefore, complementary protein intake made no conflict in renal function.