Gastrointestinal Tolerance of an Infant Formula Manufactured from Extensively Hydrolysed Protein in Healthy Term Infants

The evaluation of secondary parameters of a prospective, randomised, controlled, multicentre intervention trial aimed to analyse gastrointestinal tolerance of an infant formula manufactured from extensively hydrolysed whey protein (eHF) compared to intact cow's milk protein (control formula, CF) in healthy term infants. Infants ≤ 25 days of age, who were exclusively formula-fed, were randomised to receive eHF or CF for at least three months up to 120 days of age. An exclusively breastfed reference group (BF) was included for descriptive comparison. Infants' gastrointestinal tolerance was evaluated based on stool parameters, the Amsterdam Infant Stool Scale (AISS), the Infant Gastrointestinal Symptom Questionnaire (IGSQ), and sleeping patterns. Of 359 infants included, 297 randomised (eHF: n = 149, CF: n = 148) and 41 BF infants completed the study per protocol. All tolerance parameters were comparable between eHF and CF. Stool was predominantly soft and yellow in colour. Stool was more frequently green in eHF than CF. BF infants had more frequent stools, which were mainly watery or soft and yellow, and comparable IGSQ scores (descriptive). Irrespective of group, all gastrointestinal and sleep parameters showed signs of maturation with increasing age. In conclusion, eHF showed gastrointestinal tolerance as good as CF in healthy infants. Both formulae were well-tolerated.

Correction: Otten et al. Safety and Suitability of an Infant Formula Manufactured from Extensively Hydrolysed Protein in Healthy Term Infants. Nutrients 2023, 15, 1901

In the original publication [...].

Real-world evidence study on tolerance and growth in infants fed an infant formula with two human milk oligosaccharides vs mixed fed and exclusively breastfed infants

INTRODUCTION

Human milk oligosaccharides (HMOs) are important components of human milk having diverse functions in the development of infants. Randomized controlled trials (RCTs) have demonstrated that infant formulas with the HMOs 2'-fucosyllactose (2'FL) and lacto-N-neotetraose (LNnT) are safe, well-tolerated, and support normal growth. This study aimed to generate real-world evidence (RWE) on growth and gastrointestinal (GI) tolerance in infants consuming a formula with 1 g/L 2'FL and 0.5 g/L LNnT, including a mixed feeding group not studied before in RCTs.

PARTICIPANTS AND METHODS

This 8-week open-label prospective multicenter study was conducted in Germany and Austria, and included groups of healthy, exclusively breastfed infants (BF), exclusively formula-fed infants (FF) who received the HMO-formula, and infants mixed fed with both HMO formula and human milk (MF). Co-primary outcomes were anthropometry and gastrointestinal tolerance via validated Infant Gastrointestinal Symptom Questionnaire (IGSQ). Secondary outcomes included formula satisfaction and adverse events (AEs).

RESULTS

One-hundred six infants completed the study (46 FF, 22 MF, and 38 BF). Mean anthropometric z-scores were comparable between groups and generally within ± 0.5 of WHO medians at week 8. IGSQ composite scores demonstrated good GI tolerance in all groups with no significant group differences at week 4 or 8. IGSQ composite scores in FF improved during the course of the study and parents provided high satisfaction ratings for the HMO-formula. Four potentially product-related AEs were reported in FF (no in MF).

CONCLUSIONS

In this RWE study examining an infant formula with HMOs, growth and GI tolerance outcomes were confirming the good tolerance and safety of this early feeding option previously reported in RCTs.

Safety and Suitability of an Infant Formula Manufactured from Extensively Hydrolysed Protein in Healthy Term Infants

We aimed to demonstrate that healthy term infants experience noninferior growth with infant formula manufactured from extensively hydrolysed whey protein (eHF) compared to intact cow's milk protein (control formula, CF). This prospective, randomised, double-blind, parallel-group, controlled, multicentre trial included healthy term infants who were exclusively formula-fed. Infants ≤ 25 days of age received eHF or CF for at least three months up to 120 days of age, with a follow-up until 180 days of age. A reference group included exclusively breastfed infants (BF). Of 318 infants randomised, 297 (148 CF, 149 eHF) completed the study per protocol. Weight gain up to 120 days of age was noninferior (margin -3.0 g/day) in eHF (28.95 (95% CI: 27.21; 30.68) g/day) compared to CF (28.85 (95% CI: 27.10; 30.61) g/day) with a difference in means of 0.09 g/day and a lower limit of the one-sided 97.5% CI of -0.86 g/day (p < 0.0001 for noninferiority testing). Weight gain remained comparable during follow-up. Further anthropometric parameters did not differ between the infant formula groups throughout the study. Growth was comparable in BF. No relevant safety issues were observed. To conclude, eHF meets infant requirements for adequate growth during the first six months of life and can be considered safe and suitable.

[Single dose of misoprostol for abortion until 9 weeks of gestation]

OBJECTIVES

The primary objective was to compare the efficacy of a single-dose misoprostol for abortion before 7 weeks of gestation and between 7 and 9 weeks of gestation. The secondary objectives were to compare the amount of misoprostol required for complete expulsion, the need for endo-uterine aspiration, and to assess pain and patient experience in these two groups.

METHODS

This was a single-centre prospective observational study conducted at the University Hospitals of Strasbourg from 1st October 2019 to 31st December 2020.

RESULTS

A total of 306 patients were included, 150 in the group before 7 weeks of gestation and 156 in the group between 7 and 9 weeks of gestation. There was no significant difference in the success rate of the single dose of misoprostol between the two groups with 34.7 and 37.8% respectively (P=0.63). After taking painkillers, there is no difference in terms of pain relief (EN ≤ 4 for 92 et 95% of patients P=0.37).

CONCLUSION

The single dose of misoprostol for in-hospital abortion is as effective between 7 and 9 weeks of gestation as it is before 7. By extension, therefore, we would suggest that there should be no difference in efficacy between home abortions before 7 weeks of gestation and between 7 and 9 weeks of gestation and therefore suggest that home abortions can be performed up to 9 weeks of gestation without fear of a decrease in the rate of complete expulsion and the efficacy of analgesia, with potentially less use of misoprostol compared with the hospital setting.

Recommendations for diagnosing and managing individuals with glutaric aciduria type 1: Third revision

Glutaric aciduria type 1 is a rare inherited neurometabolic disorder of lysine metabolism caused by pathogenic gene variations in GCDH (cytogenic location: 19p13.13), resulting in deficiency of mitochondrial glutaryl-CoA dehydrogenase (GCDH) and, consequently, accumulation of glutaric acid, 3-hydroxyglutaric acid, glutaconic acid and glutarylcarnitine detectable by gas chromatography/mass spectrometry (organic acids) and tandem mass spectrometry (acylcarnitines). Depending on residual GCDH activity, biochemical high and low excreting phenotypes have been defined. Most untreated individuals present with acute onset of striatal damage before age 3 (to 6) years, precipitated by infectious diseases, fever or surgery, resulting in irreversible, mostly dystonic movement disorder with limited life expectancy. In some patients, striatal damage develops insidiously. In recent years, the clinical phenotype has been extended by the finding of extrastriatal abnormalities and cognitive dysfunction, preferably in the high excreter group, as well as chronic kidney failure. Newborn screening is the prerequisite for pre-symptomatic start of metabolic treatment with low lysine diet, carnitine supplementation and intensified emergency treatment during catabolic episodes, which, in combination, have substantially improved neurologic outcome. In contrast, start of treatment after onset of symptoms cannot reverse existing motor dysfunction caused by striatal damage. Dietary treatment can be relaxed after the vulnerable period for striatal damage, that is, age 6 years. However, impact of dietary relaxation on long-term outcomes is still unclear. This third revision of evidence-based recommendations aims to re-evaluate previous recommendations (Boy et al., J Inherit Metab Dis, 2017;40(1):75-101; Kolker et al., J Inherit Metab Dis 2011;34(3):677-694; Kolker et al., J Inherit Metab Dis, 2007;30(1):5-22) and to implement new research findings on the evolving phenotypic diversity as well as the impact of non-interventional variables and treatment quality on clinical outcomes.

Burden of Early Life Obesity and Its Relationship with Protein Intake in Infancy: The Middle East Expert Consensus

Adequate nutrition in early life is proposed to shape a child's future health by launching the growth trajectory in the proper direction, which helps to avoid negative metabolic programming effects. Protein intake during infancy and early childhood is of great importance, as it plays a key role in infant metabolic programming and the future risk of obesity. Breastfeeding provides the best nutrition in early life, with many benefits tailored for the baby, including the appropriate quantity and quality of proteins. Considering the high prevalence of childhood, and subsequent adult, obesity in the region, a virtual Middle East expert consensus meeting was held to discuss an effective approach for managing childhood obesity. Leading pediatric experts from Bahrain, Egypt, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates participated in the meeting. The experts discussed, debated, and agreed on certain directions, including the importance of educating parents, endorsing breastfeeding, and ensuring optimum quantity and quality intake of proteins in early life. This expert consensus may serve as the starting point for healthcare professionals in the region who are interested in shaping a healthy future for the generations to come.

Impact of an Infant Formula Containing a Novel Fat Blend (Cow's Milk Fat, Fish and Vegetable Oil) and Prebiotics on Stool Fatty Acid Soaps and Erythrocyte Fatty Acid Profiles in Full-Term Healthy Newborns

INTRODUCTION

Recently, new commercial infant formulas have been composed considering novel fat blends and oligosaccharides to better resemble the fatty acid (FA) composition and stereospecific distribution (e.g., increased amount of ß-palmitate) as well as probiotics content of human breast milk. We hypothesized that these newly composed infant formulas may decrease fecal FA soap excretion and may positively affect erythrocyte FA profiles compared with regular formulas.

METHODS

Healthy infants were randomly assigned to receive a high-sn-2-palmitate formula (>25% of the PA is esterified to the sn-2 position of the glycerol backbone, verum: n = 30) or a "standard" formula containing <10% of PA in sn-2 position and no oligosaccharides (control: n = 27); a non-randomized group of breast-fed infants served as control. Anthropometric data of the infants (body weight, recumbent length, and head circumference) were recorded at inclusion (visit 1) and 6 and 12 weeks after onset of intervention (visits 2 and 3). Blood samples for erythrocyte FA analysis (gas chromatography) were taken at visits 1 and 2; stool samples were collected at visit 2.

RESULTS

Quantitative formula intake (mL/kg body weight × day) at visit 2 (verum: 155 ± 30, control: 164 ± 30) and visit 3 (verum: 134 ± 26, control: 134 ± 21) was comparable. Six weeks after onset of intervention, stool total FA soaps, palmitate soaps, and total FAs were similar in both formula-fed groups but significantly higher than in breast-fed infants. During the 6-week intervention, erythrocyte palmitate decreased significantly from baseline in all 3 groups with no group differences (verum: 29.20 ± 1.17 to 27.12 ± 0.66, control: 29.88 ± 2.00 to 27.01 ± 0.94, breast-fed: 30.20 ± 0.86 to 26.84 ± 0.98). For selected FAs, significant changes over time in verum and control group were obvious but without formula effects. Some variations in the FA profile of breast-fed infants compared to both verum and control groups were observed.

CONCLUSIONS

In contrast to our hypothesis, feeding a newly composed infant formula based on a fat blend with 25% of PA in the sn-2 position of triacylglycerols and supplemented with a prebiotic could not decrease insoluble FA soap excretion compared with a standard product; in this respect, breastfeeding is obviously the best choice. Surprisingly, erythrocyte FA profiles were comparable in formula-fed and breast-fed infants; obvious alterations in FA composition of the respective fat sources and structure did not affect FA incorporation into membranes. Caution should be, however, exercised in drawing robust conclusions in the absence of larger, adequately powered intervention studies.

Infant formula with cow's milk fat and prebiotics affects intestinal flora, but not the incidence of infections during infancy in a double-blind randomized controlled trial

Background

The postnatal intestinal colonization of human milk-fed and formula-fed infants differs substantially, as does the susceptibility to infectious diseases during infancy. Specific ingredients in human milk, such as prebiotic human milk oligosaccharides and a specifically structured fat composition with high proportion of beta-palmitic acid (beta-PA) promote the growth of intestinal bifidobacteria, which are associated with favorable effects on infants’ health. The present study investigates whether addition of prebiotic galactooligosaccharides (GOS) in combination with higher amounts of beta-PA from cow’s milk fat in infant formula positively affects gut microbiota and the incidence of infections in formula-fed infants.

Methods

In a double-blind controlled trial, formula-fed infants were randomly assigned to either receive an experimental formula containing a higher proportion of beta-PA (20–25%) from natural cow’s milk fat, and a prebiotic supplement (0.5 g GOS/100 ml), or a standard infant formula with low beta-PA (< 10%), without prebiotics. A breast-fed reference group was also enrolled. After 12 weeks, fecal samples were collected to determine the proportion of fecal bifidobacteria. The number of infections during the first year of life was recorded.

Results

After 12 weeks, the proportion of fecal bifidobacteria was significantly higher in infants receiving formula with high beta-PA and GOS compared to control, and was similar to the breast-fed group (medians 8.8%, 2.5%, and 5.0% respectively; p < 0.001). The incidence of gastrointestinal or other infections during the first year of life did not differ between groups.

Conclusions

The combination of higher amounts of beta-PA plus GOS increased significantly the proportion of fecal bifidobacteria in formula-fed infants, but did not affect the incidence of infections.

Trial registration

The study protocol was registered with Clinical Trials (Protocol Registration and Results System Trial ID: NCT01603719) on 05/15/2012 (retrospectively registered).

Vegetarian diets in childhood and adolescence : Position paper of the nutrition committee, German Society for Paediatric and Adolescent Medicine (DGKJ)

In Western countries, vegetarian diets are associated with lower intakes of energy, saturated fatty acids and animal protein and higher intakes of fibre and phytochemicals, compared to omnivorous diets. Whether the corresponding health benefits in vegetarians outweigh the risks of nutrient deficiencies has not been fully clarified. It should be noted that vegetarians often have a higher socioeconomic status, follow a more health-conscious lifestyle with higher physical activity, and refrain from smoking more often than non-vegetarians. The nutritional needs of growing children and adolescents can generally be met through a balanced, vegetable-based diet; however, due to their higher nutrient requirements per kilogramme of body weight, vegetarian children have a higher risk for developing nutrient deficiencies than adults. With a vegetarian diet, the mean intakes of some nutrients, such as the omega-3 fatty acid docosahexaenoic acid (DHA), are lower than in omnivores or those eating fish. For other nutrients, such as iron and zinc, the bioavailability from vegetable foodstuffs is reduced when the intake of phytates and fibre is high; thus, the prevalence of iron deficiency can be increased despite high vitamin C intake. In addition, vitamin B12 is only found in animal-source foods. Vitamin B12 should be supplemented in people of all age groups who follow a strict vegan diet without consuming animal products. A vegetarian diet in childhood and adolescence requires good information and supervision by a paediatrician, if necessary, in cooperation with an appropriately trained dietary specialist.

[Temporary urethral stents changes as an alternative treatment for neurological bladder]

BACKGROUND

Patients with detrusor-sphincter dysynergia (DSD) who are unable to perform self-catheterisation can benefit from an endoscopic treatment. We chose regular urethral stent changes as an alternative to sphincterotomy in this kind of patients. The purpose of this study is to show that temporary urethral stents changes represent a treatment option with a reasonable morbidity for patients with DSD.

METHODS

We retrospectively reviewed patients in our center who had been treated with urethral stents from April 2005 to September 2017. The stent changes were performed every 12 to 18 months depending on urethrovesical fibroscopy findings. The primary endpoint was treatment continuation.

RESULTS

A total of 44 patients were enrolled in our study and the average follow-up duration was 46 months [18.5-53.25]. Primary treatment failure was seen in 14 (32%) patients mainly due to problems related to equipment (n=3) and urinary retention (n=2). Four patients died before their first stent change. The treatment was successful in 30 (68%) patients, of whom 10 (33%) subsequently adopted a voiding mode change. We lost sight of 5 patients (11%) during follow-up. The main complications were urinary retention (29%), urinary tract infections (27%) and stent migration (18%). Fifteen (34%) experienced grade III-IV complications.

CONCLUSIONS

Regular urethral stent changes represent an alternative treatment option for patients with DSD but with a significant morbidity.

LEVEL OF EVIDENCE

4.

Mothers' Consumption of Soy Drink But Not Black Tea Increases the Flavonoid Content of Term Breast Milk: A Pilot Randomized, Controlled Intervention Study

OBJECTIVE

We performed a pilot RCT to prove the hypothesis that a controlled ingestion of polyphenol-rich beverages (soy drink, decaffeinated black tea) in nutritive dosages by nursing women has an effect on the composition (flavonoid concentration, total antioxidant capacity) of breast milk.

METHODS

Healthy nursing women were supplemented with either 250 mL of a soy drink (12 mg isoflavones; n = 18), 300 mL decaffeinated black tea (67 mg catechins; n = 18), or 300 mL water (n = 8, control) for 6 days. Milk samples were collected before, during, and after intervention. Flavonoid content (isoflavones/catechins, HPLC) and total antioxidant capacity of milk and test drinks in milk specimens were assessed.

RESULTS

Isoflavone content (genistein and daidzein) in breast milk increased up to 12 nmol/L after soy drink consumption; the major flavonoids constituents of black tea (catechin, epicatechin, and respective conjugates) could not be detected in milk samples. With both interventions, the total antioxidant capacity of breast milk was not affected.

CONCLUSIONS

Mothers' daily consumption of a soy drink considerably increases isoflavone content of breast milk resulting in an estimated daily exposure of 9.6 nmol isoflavones in a 4-month-old suckling infant. Luminal flavanol uptake from black tea consumed by the nursing mother may be too low to affect flavanol concentrations in breast milk.

Water, sodium, potassium and chloride

The sudden disruption of excessive placental supply with fluids and electrolytes is challenging for neonatal physiology during the period of postnatal adaptation. Different from many other nutrients, the body experiences large changes in daily requirements during the first 7-14 postnatal days, and on the other hand does not tolerate conditions of excess and deficiency very well. Imbalances of fluid and electrolytes are common in neonates, which--in addition--might be further aggravated by NICU treatment procedures. Therefore, fluid and electrolyte management can be one of the most challenging aspects of neonatal care of the premature infant. An understanding of the physiological adaptation process to extrauterine life--and how immaturity effects that transition--is the basis which is needed to understand and manage fluid and electrolyte balance in premature infants. This chapter addresses the physiology of postnatal adaptation and other aspects of fluid and electrolyte management (concerning potassium, sodium and chloride) of the preterm infant.

S3-Guidelines for the Treatment of Inflammatory Breast Disease during the Lactation Period: AWMF Guidelines, Registry No. 015/071 (short version) AWMF Leitlinien-Register Nr. 015/071 (Kurzfassung)

Breastfeeding is widely acknowledged to be the best and most complete form of nutrition for healthy infants born at term and is associated with numerous benefits in terms of infants' health, growth, immunity and development. However, breastfeeding problems often result in early weaning. Standardized treatment recommendations for breastfeeding-related diseases are necessary to optimize the care offered to breastfeeding women. Evidence and consensus based guidelines for the treatment of puerperal mastitis, sore nipples, engorgement and blocked ducts were developed on the initiative of the National Breastfeeding Committee. These guidelines were developed in accordance with the criteria set up by the Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF), the Association of Scientific Medical Societies in Germany. The recommendations were drawn up by an interdisciplinary group of experts and were based on a systematic search and evaluation of the literature but also took clinical experience into account. Additionally good clinical practice (GCP) in terms of expert opinion was formulated in cases where scientific investigations could not be performed or were not aimed for. This article presents a summary of the recommendations of the S3-guidelines.

Short-term use of parenteral nutrition with a lipid emulsion containing a mixture of soybean oil, olive oil, medium-chain triglycerides, and fish oil: a randomized double-blind study in preterm infants

BACKGROUND

For premature neonates needing parenteral nutrition (PN), a balanced lipid supply is crucial. The authors hypothesized that a lipid emulsion containing medium-chain triglycerides (MCTs) and soybean, olive, and fish oils would be as safe and well tolerated as a soybean emulsion while beneficially influencing the fatty acid profile.

METHODS

Double-blind, controlled study in 53 neonates (<34 weeks' gestation) randomized to receive at least 7 days of PN containing either an emulsion of MCTs and soybean, olive, and fish oils or a soybean oil emulsion. Target lipid dosage was 1.0 g fat/kg body weight [BW]/d on days 1-3, 2 g/kg BW/d on day 4, 3 g/kg BW/d on day 5, and 3.5 g/kg BW/d on days 6-14.

RESULTS

Test emulsion vs control, mean ± SD: baseline triglyceride concentrations were 0.52 ± 0.16 vs 0.54 ± 0.19 mmol/L and increased similarly in both groups to 0.69 ± 0.38 vs 0.67 ± 0.36 on day 8 of treatment (P = .781 for change). A significantly higher decrease in total and direct bilirubin vs baseline was seen in the test group compared with the control group P < .05 between groups). In plasma and red blood cell phospholipids, eicosapentaenoic acid and docosahexaenoic acid were higher, and the n-6/n-3 fatty acid ratio was lower in the test group (P < .05 vs control).

CONCLUSIONS

The lipid emulsion, based on a mixture of MCTs and soybean, olive, and fish oils, was safe and well tolerated by preterm infants while beneficially modulating the fatty acid profile.

Somatostatin - therapeutic option for chylothorax in preterm neonates. Report on two patients and review of the literature

We report the use of somatostatin in two preterm neonates with chylothorax and discuss those cases in the light of current literature on the treatment of chylothorax in infants born preterm. Chylothorax, a severe complication in thorax surgery, is also a symptom of different diseases and may even occur spontaneously. Treatment is difficult, especially in preterm neonates with co-morbidities. The standard therapeutic strategy with non-invasive procedures (e.g. enteral diet free of long chain triglycerides or parenteral nutrition) is not always effective. Surgical interventions, like pleurodesis, ligation of the ductus thoracicus, or pleuroperitoneal shunt may be of considerable risk in preterm infants and must be carefully evaluated. Somatostatin is a new non-invasive therapeutic option for the treatment of chylothorax in adults and older pediatric patients. Case reports demonstrate the effectiveness of the somatostatin treatment, mostly in adult patients and in adolescents. There are only few case reports describing the use of somatostatin in preterm neonates. One VLBW (very low birth weight) and one hypotrophic ELBW (extremely low birth weight) neonate (gestational ages of 30+3/7, and 25+2/7 weeks; birth weights of 1270g, and 450g respectively) were treated for chylothorax with continuous infusion of somatostatin in addition to the dietary treatment. The chylothorax disappeared after start of somatostatin. No major side-effects of the somatostatin treatment were observed. As reported in other published pediatric cases, somatostatin seems to be a therapeutic option for the treatment of chylothorax in preterm neonates. In review of the literature we identified another eleven case reports on the treatment of persistent chylothorax with somatostatin or octreotide in preterm neonates. Further observations are needed before somatostatin can be recommended as a standard first-line treatment procedure for chylothorax in infants.

Fortification of breast milk in VLBW infants: metabolic acidosis is linked to the composition of fortifiers and alters weight gain and bone mineralization

BACKGROUND & AIMS

Study objectives were to test (a) whether increased incidence of metabolic acidosis (MA) was caused by introduction of a new commercially available fortifier for breast milk, (b) if so, whether its modification would decrease the incidence of MA and (c) to analyze the impact of MA on growth.

METHODS

Double-blind randomized design. Healthy breast-fed infants (≤34 gestational weeks). Primary outcome measure was incidence of MA (BE < -6.0 mmol/L). Secondary outcome measures were growth, bone mineral content (BMC), vital signs, treatment with sodium hydrogen carbonate and Ca and laboratory parameters (pH, pCO₂, HCO₃⁻, electrolytes).

RESULTS

Part 1 (comparison of standard (SF) and new fortifier (NF)): Interim analysis showed MA in 1 out of 7 (SF) and 7 out of 8 (NF) infants, p = 0.01; therefore the study was interrupted; subsequently the fortifier was adapted by modifying mineral components. Part 2 (comparison of SF and reformulated fortifier (RF)): MA occurred in 3 out of 15 (SF) and 6 out of 19 (RF), p = 0.7. When data of all infants studied, those with MA had lower mean weight gain (median: 9 vs. 21 g/kg/d, p < 0.01) and lower BMC (1.6% vs. 1.9% BMC/lean, p = 0.04) at discharge.

CONCLUSIONS

When fed fortified breast milk, mild MA spontaneously may develop in 20-30% of VLBW infants. A fortifier with an inappropriate composition may increase the severity and frequency of MA. Our data show that weight gain and BMC seem to be related to acid-base homeostasis. It may be speculated that inadequate growth of fully fed preterm infants is triggered more often by imbalances of acid-base status than previously expected.

Neonatology/Paediatrics - Guidelines on Parenteral Nutrition, Chapter 13

There are special challenges in implementing parenteral nutrition (PN) in paediatric patients, which arises from the wide range of patients, ranging from extremely premature infants up to teenagers weighing up to and over 100 kg, and their varying substrate requirements. Age and maturity-related changes of the metabolism and fluid and nutrient requirements must be taken into consideration along with the clinical situation during which PN is applied. The indication, the procedure as well as the intake of fluid and substrates are very different to that known in PN-practice in adult patients, e.g. the fluid, nutrient and energy needs of premature infants and newborns per kg body weight are markedly higher than of older paediatric and adult patients. Premature infants <35 weeks of pregnancy and most sick term infants usually require full or partial PN. In neonates the actual amount of PN administered must be calculated (not estimated). Enteral nutrition should be gradually introduced and should replace PN as quickly as possible in order to minimise any side-effects from exposure to PN. Inadequate substrate intake in early infancy can cause long-term detrimental effects in terms of metabolic programming of the risk of illness in later life. If energy and nutrient demands in children and adolescents cannot be met through enteral nutrition, partial or total PN should be considered within 7 days or less depending on the nutritional state and clinical conditions.

Quality of care of VLBW neonates: relationship between unit volume and outcome is different between metropolitan and rural regions

BACKGROUND

Recent studies from predominantly rural areas in Germany show that neonatal outcome of very low birth weight (VLBW) neonates is (on average) inferior with lower NICU (neonatal intensive care unit) volume. However, there are no data available which show that study results of one specific region can be transferred to other areas with possibly different medical infrastructure and needs.

AIM

It was investigated whether a systematic difference of treatment quality between smaller (1000-2000 births/year; < or =20 neonatal beds) vs. larger neonatal centres in Berlin (>3000 births/year; >20 neonatal beds) exists. Furthermore, the results are compared to data from a rural region in order to discuss transferability between regions.

METHODS

Retrospectively, completely, and for the first time, the data of all centres which treat VLBW neonates (< or =1500 g birth weight) in the city-state of Berlin, Germany, from the years 2003/2004 were reviewed.

RESULTS

Our study showed no difference in the treatment quality of smaller vs. larger neonatal units in Berlin. This result differs from those of a study in Baden-Württemberg, a predominantly rural state, with different medical infrastructure than Berlin.

CONCLUSION

The present study suggests that regional investigations on the infrastructure vs. treatment outcome are not transferable between areas. Patient volume/unit appears inadequate for predicting the future treatment quality of neonatal departments. Direct quality indicators are stable for the assessed departments and should be preferably used to organize medical infrastructure.

Impedance index or standard anthropometric measurements, which is the better variable for predicting fat-free mass in sick children?

AIM

To compare the predictive value of impedance index (ZI, height2/impedance) with anthropometric measurements for estimating fat-free mass (FFM).

METHODS

FFM of 120 white paediatric children (46 males, 74 females), aged 2.5-18 years was measured by using dual energy X-ray absorptiometry. Weight, height, mid-upper arm circumference (MUAC), skinfold thickness (biceps, triceps, subscapular and suprailiac) and bioelectrical impedance were also obtained. Stepwise multiple regression analysis and residual plots were performed to determine the most significant variables to predict FFM.

RESULTS

The single best predictor of FFM was ZI, which explained 96.2% of the variance in FFM (r = 0.981, SEE = 2.15 kg). Addition of weight to the model containing ZI increased the explained variance of FFM to 96.6% (r = 0.983, SEE = 2.03 kg). BMI and MUAC were the poorest predictors of FFM: r = 0.422, SEE = 10.2 kg and r = 0.621, SEE = 8.93 kg, respectively.

CONCLUSION

Impedance index is a more significant single predictor of FFM than other anthropometric measurements. The predictive accuracy of bioelectrical impedance analysis-based prediction equations for FFM was improved by addition of weight.

Body composition of preterm infants measured during the first months of life: bioelectrical impedance provides insignificant additional information compared to anthropometry alone

Detailed knowledge of body composition in preterm neonates during their later postnatal period may be important for the treatment process. However, little consideration has been given to test whether bioelectrical impedance analysis (BIA) is a useful bedside method to predict fat-free mass (FFM). The aim of the study is to assess whether BIA is a bedside method to measure FFM in preterm neonates. FFM of 118 white subjects (51 males, 67 females), mean gestational age of 30.1+/-3.1 weeks and birth weight of 1.26+/-0.47 kg, was measured at a gestational age of 38.6+/-3.8 weeks and actual body weight of 2.6+/-0.54 kg using dual energy X-ray absorptiometry (FFM(DXA)). Weight (W), height (Ht), and bioelectric impedance (I) measurements were collected. Multiple regression analysis was performed to develop prediction equations to estimate FFM with impedance index (Ht(2)/I, cm(2)/Omega) and W (kg) as predictor variables. Bootstrap analysis was performed for validating the derived prediction equations. Correlations between FFM(DXA) and weight were 0.96, 0.98, and 0.97 in boys, girls, and both sexes, respectively. Those between FFM(DXA) and Ht(2)/I were: 0.73, 0.81, and 0.79. Equations used to predict FFM (kg) were for boys: FEM = 0.05Ht(2)/I + 0.68W + 0.40(R2 = 0.919) and for girls: FFM = 0.04Ht(2)/I + 0.71W + 0.29(R2 = 0.957).

CONCLUSIONS

In preterm neonates, weight is a more effective predictor of FFM than impedance index. The study provides a bedside procedure for estimating FFM, mainly based on anthropometric parameters rather than BIA.

Use of bioelectrical impedance analysis and anthropometry to measure fat-free mass in children and adolescents with Crohn disease

OBJECTIVES

To investigate the precision of published prediction equations for fat-free mass (FFM) from bioimpedance measurements in children with Crohn disease using dual-energy X-ray absorptiometry (DXA) as an in vivo gold standard.

METHODS

Fat-free mass of 49 white boys and girls ages 7.3 to 16.9 y suffering from Crohn disease was measured by DXA. Body weight, height and bioimpedance measurements were also collected. FFM measured by DXA (FFM(DXA)) was compared with FFM predicted by the only 5 published prediction equations available for children and adolescents. An equation was developed for predicting FFM and was validated using a bootstrap method.

RESULTS

When correlating predicted FFM with FFM(DXA), Schaefer's equation showed the highest R2 (0.950), the smallest standard error of estimate (SEE) (2.05 kg) and the smallest percentage error (0.28%). Our prediction equation for estimating FFM was FFM = 0.652 Ht2/Z + 0.0385 Wt + 0.586 Age - 0.327, R2 = 0.951, SEE = 2.08, P < 0.0005, where Ht2/Z is the impedance index in cm2/ohm, Wt is body weight in kilograms, age is in years. R2 value from bootstrap method was 0.950 +/- 0.01 (95% confidence interval 0.927-0.968), indicating an acceptable validation of the derived formula.

CONCLUSIONS

The formula of Schaefer is the best for predicting FFM. The present study provides a new prediction equation for estimating FFM in children with Crohn disease that may be used in clinical settings in which more sophisticated body composition measuring equipments are not available.