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Minarski M, Maas C, Heinrich C, Böckmann KA, Bernhard W, Shunova A, Poets CF, Franz AR. Choline and Betaine Levels in Plasma Mirror Choline Intake in Very Preterm Infants. Nutrients 2023; 15:4758. [PMID: 38004152 PMCID: PMC10675502 DOI: 10.3390/nu15224758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/07/2023] [Accepted: 11/10/2023] [Indexed: 11/26/2023] Open
Abstract
Choline is essential for cell membrane formation and methyl transfer reactions, impacting parenchymal and neurological development. It is therefore enriched via placental transfer, and fetal plasma concentrations are high. In spite of the greater needs of very low birth weight infants (VLBWI), choline content of breast milk after preterm delivery is lower (median (p25-75): 158 mg/L (61-360 mg/L) compared to term delivery (258 mg/L (142-343 mg/L)). Even preterm formula or fortified breast milk currently provide insufficient choline to achieve physiological plasma concentrations. This secondary analysis of a randomized controlled trial comparing growth of VLBWI with different levels of enteral protein supply aimed to investigate whether increased enteral choline intake results in increased plasma choline, betaine and phosphatidylcholine concentrations. We measured total choline content of breast milk from 33 mothers of 34 VLBWI. Enteral choline intake from administered breast milk, formula and fortifier was related to the respective plasma choline, betaine and phosphatidylcholine concentrations. Plasma choline and betaine levels in VLBWI correlated directly with enteral choline intake, but administered choline was insufficient to achieve physiological (fetus-like) concentrations. Hence, optimizing maternal choline status, and the choline content of milk and fortifiers, is suggested to increase plasma concentrations of choline, ameliorate the choline deficit and improve growth and long-term development of VLBWI.
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Affiliation(s)
- Michaela Minarski
- Department of Neonatology, University Children’s Hospital, Tübingen University Hospital, 72076 Tübingen, Germany (W.B.)
| | - Christoph Maas
- Department of Neonatology, University Children’s Hospital, Tübingen University Hospital, 72076 Tübingen, Germany (W.B.)
| | - Christine Heinrich
- Department of Neonatology, University Children’s Hospital, Tübingen University Hospital, 72076 Tübingen, Germany (W.B.)
| | - Katrin A. Böckmann
- Department of Neonatology, University Children’s Hospital, Tübingen University Hospital, 72076 Tübingen, Germany (W.B.)
| | - Wolfgang Bernhard
- Department of Neonatology, University Children’s Hospital, Tübingen University Hospital, 72076 Tübingen, Germany (W.B.)
| | - Anna Shunova
- Department of Neonatology, University Children’s Hospital, Tübingen University Hospital, 72076 Tübingen, Germany (W.B.)
| | - Christian F. Poets
- Department of Neonatology, University Children’s Hospital, Tübingen University Hospital, 72076 Tübingen, Germany (W.B.)
| | - Axel R. Franz
- Department of Neonatology, University Children’s Hospital, Tübingen University Hospital, 72076 Tübingen, Germany (W.B.)
- Center for Pediatric Clinical Studies, University Children’s Hospital, Tübingen University Hospital, 72076 Tübingen, Germany
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Böckmann KA, Bernhard W, Minarski M, Shunova A, Wiechers C, Poets CF, Franz AR. Choline supplementation for preterm infants: metabolism of four Deuterium-labeled choline compounds. Eur J Nutr 2023; 62:1195-1205. [PMID: 36460779 PMCID: PMC10030424 DOI: 10.1007/s00394-022-03059-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 11/16/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Supply of choline is not guaranteed in current preterm infant nutrition. Choline serves in parenchyma formation by membrane phosphatidylcholine (PC), plasma transport of poly-unsaturated fatty acids (PUFA) via PC, and methylation processes via betaine. PUFA-PC concentrations are high in brain, liver and lung, and deficiency may result in developmental disorders. We compared different deuterated (D9-) choline components for kinetics of D9-choline, D9-betaine and D9-PC. METHODS Prospective study (1/2021-12/2021) in 32 enterally fed preterm infants (28 0/7-32 0/7 weeks gestation). Patients were randomized to receive enterally a single dose of 2.7 mg/kg D9-choline-equivalent as D9-choline chloride, D9-phosphoryl-choline, D9-glycerophosphorylcholine (D9-GPC) or D9-1-palmitoyl-2-oleoyl-PC(D9-POPC), followed by blood sampling at 1 + 24 h or 12 + 60 h after administration. Plasma concentrations were analyzed by tandem mass spectrometry. Results are expressed as median (25th/75th percentile). RESULTS At 1 h, plasma D9-choline was 1.8 (0.9/2.2) µmol/L, 1.3 (0.9/1.5) µmol/L and 1.2 (0.7/1.4) µmol/L for D9-choline chloride, D9-GPC and D9-phosphoryl-choline, respectively. D9-POPC did not result in plasma D9-choline. Plasma D9-betaine was maximal at 12 h, with lowest concentrations after D9-POPC. Maximum plasma D9-PC values at 12 h were the highest after D9-POPC (14.4 (9.1/18.9) µmol/L), compared to the other components (D9-choline chloride: 8.1 [5.6/9.9] µmol/L; D9-GPC: 8.4 (6.2/10.3) µmol/L; D9-phosphoryl-choline: 9.8 (8.6/14.5) µmol/L). Predominance of D9-PC comprising linoleic, rather than oleic acid, indicated fatty-acyl remodeling of administered D9-POPC prior to systemic delivery. CONCLUSION D9-Choline chloride, D9-GPC and D9-phosphoryl-choline equally increased plasma D9-choline and D9-betaine. D9-POPC shifted metabolism from D9-betaine to D9-PC. Combined supplementation of GPC and (PO) PC may be best suited to optimize choline supply in preterm infants. Due to fatty acid remodeling of (PO) PC during its assimilation, PUFA co-supplementation with (PO) PC may increase PUFA-delivery to critical organs. This study was registered (22.01.2020) at the Deutsches Register Klinischer Studien (DRKS) (German Register for Clinical Studies), DRKS00020502. STUDY REGISTRATION This study was registered at the Deutsches Register Klinischer Studien (DRKS) (German Register for Clinical Studies), DRKS00020502.
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Affiliation(s)
- Katrin A Böckmann
- Department of Neonatology, Faculty of Medicine, Eberhard Karls University, Calwer Straße 7, 72076, Tuebingen, Germany.
| | - Wolfgang Bernhard
- Department of Neonatology, Faculty of Medicine, Eberhard Karls University, Calwer Straße 7, 72076, Tuebingen, Germany
| | - Michaela Minarski
- Department of Neonatology, Faculty of Medicine, Eberhard Karls University, Calwer Straße 7, 72076, Tuebingen, Germany
| | - Anna Shunova
- Department of Neonatology, Faculty of Medicine, Eberhard Karls University, Calwer Straße 7, 72076, Tuebingen, Germany
| | - Cornelia Wiechers
- Department of Neonatology, Faculty of Medicine, Eberhard Karls University, Calwer Straße 7, 72076, Tuebingen, Germany
| | - Christian F Poets
- Department of Neonatology, Faculty of Medicine, Eberhard Karls University, Calwer Straße 7, 72076, Tuebingen, Germany
| | - Axel R Franz
- Department of Neonatology, Faculty of Medicine, Eberhard Karls University, Calwer Straße 7, 72076, Tuebingen, Germany
- Center for Pediatric Clinical Studies, Eberhard Karls University, Tübingen, Germany
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Bernhard W, Raith M, Shunova A, Lorenz S, Böckmann K, Minarski M, Poets CF, Franz AR. Choline Kinetics in Neonatal Liver, Brain and Lung-Lessons from a Rodent Model for Neonatal Care. Nutrients 2022; 14:nu14030720. [PMID: 35277079 PMCID: PMC8837973 DOI: 10.3390/nu14030720] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/03/2022] [Accepted: 02/05/2022] [Indexed: 02/06/2023] Open
Abstract
Choline requirements are high in the rapidly growing fetus and preterm infant, mainly serving phosphatidylcholine (PC) synthesis for parenchymal growth and one-carbon metabolism via betaine. However, choline metabolism in critical organs during rapid growth is poorly understood. Therefore, we investigated the kinetics of D9-choline and its metabolites in the liver, plasma, brain and lung in 14 d old rats. Animals were intraperitoneally injected with 50 mg/kg D9-choline chloride and sacrificed after 1.5 h, 6 h and 24 h. Liver, plasma, lungs, cerebrum and cerebellum were analyzed for D9-choline metabolites, using tandem mass spectrometry. In target organs, D9-PC and D9-betaine comprised 15.1 ± 1.3% and 9.9 ± 1.2% of applied D9-choline at 1.5 h. D9-PC peaked at 1.5 h in all organs, and decreased from 1.5-6 h in the liver and lung, but not in the brain. Whereas D9-labeled PC precursors were virtually absent beyond 6 h, D9-PC increased in the brain and lung from 6 h to 24 h (9- and 2.5-fold, respectively) at the expense of the liver, suggesting PC uptake from the liver via plasma rather than local synthesis. Kinetics of D9-PC sub-groups suggested preferential hepatic secretion of linoleoyl-PC and acyl remodeling in target organs. D9-betaine showed rapid turnover and served low-level endogenous (D3-)choline synthesis. In conclusion, in neonatal rats, exogenous choline is rapidly metabolized to PC by all organs. The liver supplies the brain and lung directly with PC, followed by organotypic acyl remodeling. A major fraction of choline is converted to betaine, feeding the one-carbon pool and this must be taken into account when calculating choline requirements.
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Affiliation(s)
- Wolfgang Bernhard
- Department of Neonatology, University Children’s Hospital, Tübingen University Hospital, 72076 Tübingen, Baden-Wuerttemberg, Germany; (A.S.); (S.L.); (K.B.); (M.M.); (C.F.P.); (A.R.F.)
- Correspondence:
| | - Marco Raith
- Max-Planck-Institut für Psychiatrie, 80804 Munich, Bavaria, Germany;
| | - Anna Shunova
- Department of Neonatology, University Children’s Hospital, Tübingen University Hospital, 72076 Tübingen, Baden-Wuerttemberg, Germany; (A.S.); (S.L.); (K.B.); (M.M.); (C.F.P.); (A.R.F.)
| | - Stephan Lorenz
- Department of Neonatology, University Children’s Hospital, Tübingen University Hospital, 72076 Tübingen, Baden-Wuerttemberg, Germany; (A.S.); (S.L.); (K.B.); (M.M.); (C.F.P.); (A.R.F.)
| | - Katrin Böckmann
- Department of Neonatology, University Children’s Hospital, Tübingen University Hospital, 72076 Tübingen, Baden-Wuerttemberg, Germany; (A.S.); (S.L.); (K.B.); (M.M.); (C.F.P.); (A.R.F.)
| | - Michaela Minarski
- Department of Neonatology, University Children’s Hospital, Tübingen University Hospital, 72076 Tübingen, Baden-Wuerttemberg, Germany; (A.S.); (S.L.); (K.B.); (M.M.); (C.F.P.); (A.R.F.)
| | - Christian F. Poets
- Department of Neonatology, University Children’s Hospital, Tübingen University Hospital, 72076 Tübingen, Baden-Wuerttemberg, Germany; (A.S.); (S.L.); (K.B.); (M.M.); (C.F.P.); (A.R.F.)
| | - Axel R. Franz
- Department of Neonatology, University Children’s Hospital, Tübingen University Hospital, 72076 Tübingen, Baden-Wuerttemberg, Germany; (A.S.); (S.L.); (K.B.); (M.M.); (C.F.P.); (A.R.F.)
- Center for Pediatric Clinical Studies, University Children’s Hospital, Tübingen University Hospital, 72076 Tübingen, Baden-Wuerttemberg, Germany
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Wiechers C, Avellina V, Luger B, Böckmann K, Minarski M, Maas C, Bernhard W, Poets CF, Franz AR. Body Composition of Preterm Infants following Rapid Transition to Enteral Feeding. Neonatology 2022; 119:246-254. [PMID: 35038714 DOI: 10.1159/000521032] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/12/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE This study aimed to evaluate body composition at the time of hospital discharge in very preterm infants following rapid transition to full enteral feeding. STUDY DESIGN We conducted a prospective, observational, cross-sectional study and included 105 preterm infants <32 gestational age or birth weight <1,500 g, born between April 2015 and December 2020, following rapid transition to full enteral feeding (≥140 mL/kg/day). Fat mass/total body mass (BF%) and fat-free mass (FFM) were measured at the time of hospital discharge using air displacement plethysmography. RESULTS Median and interquartile range (Q1-Q3) of gestational age at birth (GA) was 27.3 (26.1-28.7) weeks and birth weight 845 (687-990) g. Time to reach full enteral feeding was 5 (5-7) days. At 37.6 weeks (36.1-39.0) postmenstrual age (PMA), BF% was 17.0% (14.9-19.8) and FFM 2,161 g (1,966-2,432). BF% was not associated with GA, and not different between small and appropriate for gestational age infants. FFM was significantly lower in infants born small for gestational age. CONCLUSIONS Following rapid transition to full enteral feeding, FFM and BF% at discharge were similar to other preterm populations. BF% and FFM were not associated with GA at birth but with PMA at measurement. FFM was lower and BF% higher compared to term infants at birth, suggesting diminished parenchymal growth in preterm infants. Continued monitoring of body composition, metabolic health, and neurological development is needed to study long-term effects.
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Affiliation(s)
- Cornelia Wiechers
- Department of Neonatology, University Children's Hospital, Eberhard Karls University, Tübingen, Germany
| | - Vanessa Avellina
- Department of Neonatology, University Children's Hospital, Eberhard Karls University, Tübingen, Germany
| | - Beate Luger
- Department of Neonatology, University Children's Hospital, Eberhard Karls University, Tübingen, Germany
| | - Katrin Böckmann
- Department of Neonatology, University Children's Hospital, Eberhard Karls University, Tübingen, Germany
| | - Michaela Minarski
- Department of Neonatology, University Children's Hospital, Eberhard Karls University, Tübingen, Germany
| | - Christoph Maas
- Department of Neonatology, University Children's Hospital, Eberhard Karls University, Tübingen, Germany
| | - Wolfgang Bernhard
- Department of Neonatology, University Children's Hospital, Eberhard Karls University, Tübingen, Germany
| | - Christian F Poets
- Department of Neonatology, University Children's Hospital, Eberhard Karls University, Tübingen, Germany
| | - Axel R Franz
- Department of Neonatology, University Children's Hospital, Eberhard Karls University, Tübingen, Germany.,Center for Pediatric Clinical Studies, University Children`s Hospital, Eberhard Karls University, Tübingen, Germany
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Böckmann KA, von Stumpff A, Bernhard W, Shunova A, Minarski M, Frische B, Warmann S, Schleicher E, Poets CF, Franz AR. Fatty acid composition of adipose tissue at term indicates deficiency of arachidonic and docosahexaenoic acid and excessive linoleic acid supply in preterm infants. Eur J Nutr 2020; 60:861-872. [PMID: 32476053 PMCID: PMC7900037 DOI: 10.1007/s00394-020-02293-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 05/21/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Arachidonic (ARA) and docosahexaenoic acid (DHA) are constitutive to membrane phospholipids, and essential for brain and overall development. ARA/DHA pools in term infants (TI) are built during the third trimester, stored as adipose tissue triglycerides and predominantly distributed via plasma phosphatidylcholine (PC). In preterm infants (PTI), placental ARA/DHA supply is replaced by linoleic-acid (LA)-enriched nutrition. This study aimed to investigate the impact of PTI nutrition, compared to placental supply, on fatty acid composition in adipose tissue and blood. METHODS Prospective observational study (4/2017-3/2019) in 12 PTI and 3 PTI with enterostomy (PTI/E) (gestational age (GA) < 32 weeks) with surgical intervention at term (± 6 weeks) and 14 TI (GA ≥ 34 weeks, surgical intervention < 2 weeks postnatally). PTI/E were analyzed descriptively only. PC and triglyceride fatty acids were analyzed with tandem mass spectrometry and gas chromatography, respectively. Results were compared between TI and PTI with Wilcoxon Test and shown as median [25th percentile-75th percentile] mol%. RESULTS PTI had less ARA in adipose tissue TG (0.77[0.67-0.87]% vs. 1.04[0.95-1.14]%, p = 0.0003) and plasma PC (20.7[18.7-22.8]% vs. 28.3[22.7-33.5]%, p = 0.011) than TI. PTI also had less DHA in adipose tissue TG (0.6[0.4-0.8]% vs. 1.1[0.8-1.4]%, p = 0.006) and plasma PC (6.4[5.6-7.1]% vs. 8.4[7.8-13.1]%, p = 0.002). LA was increased in PTI's adipose tissue TG (10.0[8.8-12.3]% vs. 3.0[2.5-3.6]%, p < 0.0001) and plasma PC (48.4[44.6-49.6]% vs. 30.6[24.9-35.6]%, p = 0.0002). Similar differences were observed in erythrocyte PC. CONCLUSION In PTI, LA is increased and ARA/DHA decreased in adipose tissue, plasma and erythrocyte lipids as proxies for other tissues, likely caused by PTI nutrition. This may contribute to impaired PTI development.
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Affiliation(s)
- K A Böckmann
- Department of Neonatology, Faculty of Medicine, Eberhard-Karls-University, Calwer Straße 7, 72076, Tübingen, Germany.
| | - A von Stumpff
- Department of Neonatology, Faculty of Medicine, Eberhard-Karls-University, Calwer Straße 7, 72076, Tübingen, Germany
| | - W Bernhard
- Department of Neonatology, Faculty of Medicine, Eberhard-Karls-University, Calwer Straße 7, 72076, Tübingen, Germany
| | - A Shunova
- Department of Neonatology, Faculty of Medicine, Eberhard-Karls-University, Calwer Straße 7, 72076, Tübingen, Germany
| | - M Minarski
- Department of Neonatology, Faculty of Medicine, Eberhard-Karls-University, Calwer Straße 7, 72076, Tübingen, Germany
| | - B Frische
- Department of Neonatology, Faculty of Medicine, Eberhard-Karls-University, Calwer Straße 7, 72076, Tübingen, Germany
| | - S Warmann
- Department of Pediatric Surgery and Child Urology, Faculty of Medicine, Eberhard-Karls-University, Tübingen, Germany
| | - E Schleicher
- Department of Internal Medicine IV, Faculty of Medicine, Eberhard-Karls-University, Tübingen, Germany
| | - C F Poets
- Department of Neonatology, Faculty of Medicine, Eberhard-Karls-University, Calwer Straße 7, 72076, Tübingen, Germany
| | - A R Franz
- Department of Neonatology, Faculty of Medicine, Eberhard-Karls-University, Calwer Straße 7, 72076, Tübingen, Germany
- Center for Pediatric Clinical Studies, Faculty of Medicine, Eberhard-Karls-University, Tübingen, Germany
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Minarski M, Maas C, Engel C, Heinrich C, Böckmann K, Bernhard W, Poets CF, Franz AR. Calculating Protein Content of Expressed Breast Milk to Optimize Protein Supplementation in Very Low Birth Weight Infants with Minimal Effort-A Secondary Analysis. Nutrients 2020; 12:nu12051231. [PMID: 32349215 PMCID: PMC7282015 DOI: 10.3390/nu12051231] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/18/2020] [Accepted: 04/22/2020] [Indexed: 11/16/2022] Open
Abstract
Breast milk does not meet the nutritional needs of preterm infants, necessitating fortification. Breast milk is particularly variable in protein content, hence standardized (fixed dosage) supplementation results in inadequate supply. This was a secondary analysis of 589 breast milk protein content measurements of 51 mothers determined by mid-infrared spectroscopy during a clinical trial of higher versus lower protein supplementation in very low birth weight infants. Mothers (and breast milk samples) were divided into a test (41 mothers) and a validation cohort (10 mothers). In the test cohort, the decrease in protein content by day of lactation was modeled resulting in the breast milk-equation (BME)). In the validation cohort, five supplementation strategies to optimize protein supply were compared: standardized supplementation (adding 1.0 g (S1) or 1.42 g protein/100 mL (S2)) was compared with 'adapted' supplementation, considering variation in protein content (protein content according to Gidrewicz and Fenton (A1), to BME (A2) and to BME with adjustments at days 12 and 26 (A3)). S1 and S2 achieved 5% and 24% of adequate protein supply, while the corresponding values for A1-A3 were 89%, 96% and 95%. Adapted protein supplementation based on calculated breast milk protein content is easy, non-invasive, inexpensive and improves protein supply compared to standardized supplementation.
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Affiliation(s)
- Michaela Minarski
- Department of Neonatology, University Children’s Hospital, Tübingen University Hospital, 72076 Tübingen, Baden-Wuerttemberg, Germany; (C.M.); (C.H.); (K.B.); (W.B.); (C.F.P.); (A.R.F.)
- Correspondence: ; Tel.: +49-7071-2984742; Fax: +49-7071293969
| | - Christoph Maas
- Department of Neonatology, University Children’s Hospital, Tübingen University Hospital, 72076 Tübingen, Baden-Wuerttemberg, Germany; (C.M.); (C.H.); (K.B.); (W.B.); (C.F.P.); (A.R.F.)
| | - Corinna Engel
- Center for Pediatric Clinical Studies, University Children’s Hospital, Tübingen University Hospital, 72076 Tübingen, Baden-Wuerttemberg, Germany;
| | - Christine Heinrich
- Department of Neonatology, University Children’s Hospital, Tübingen University Hospital, 72076 Tübingen, Baden-Wuerttemberg, Germany; (C.M.); (C.H.); (K.B.); (W.B.); (C.F.P.); (A.R.F.)
| | - Katrin Böckmann
- Department of Neonatology, University Children’s Hospital, Tübingen University Hospital, 72076 Tübingen, Baden-Wuerttemberg, Germany; (C.M.); (C.H.); (K.B.); (W.B.); (C.F.P.); (A.R.F.)
| | - Wolfgang Bernhard
- Department of Neonatology, University Children’s Hospital, Tübingen University Hospital, 72076 Tübingen, Baden-Wuerttemberg, Germany; (C.M.); (C.H.); (K.B.); (W.B.); (C.F.P.); (A.R.F.)
| | - Christian F Poets
- Department of Neonatology, University Children’s Hospital, Tübingen University Hospital, 72076 Tübingen, Baden-Wuerttemberg, Germany; (C.M.); (C.H.); (K.B.); (W.B.); (C.F.P.); (A.R.F.)
| | - Axel R Franz
- Department of Neonatology, University Children’s Hospital, Tübingen University Hospital, 72076 Tübingen, Baden-Wuerttemberg, Germany; (C.M.); (C.H.); (K.B.); (W.B.); (C.F.P.); (A.R.F.)
- Center for Pediatric Clinical Studies, University Children’s Hospital, Tübingen University Hospital, 72076 Tübingen, Baden-Wuerttemberg, Germany;
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