Effects of lactose intake on lactose digestion and colonic fermentation in preterm infants

Enteral Nutrition in Preterm Infants (2022): A Position Paper From the ESPGHAN Committee on Nutrition and Invited Experts

OBJECTIVES

To review the current literature and develop consensus conclusions and recommendations on nutrient intakes and nutritional practice in preterm infants with birthweight <1800 g.

METHODS

The European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Committee of Nutrition (CoN) led a process that included CoN members and invited experts. Invited experts with specific expertise were chosen to represent as broad a geographical spread as possible. A list of topics was developed, and individual leads were assigned to topics along with other members, who reviewed the current literature. A single face-to-face meeting was held in February 2020. Provisional conclusions and recommendations were developed between 2020 and 2021, and these were voted on electronically by all members of the working group between 2021 and 2022. Where >90% consensus was not achieved, online discussion meetings were held, along with further voting until agreement was reached.

RESULTS

In general, there is a lack of strong evidence for most nutrients and topics. The summary paper is supported by additional supplementary digital content that provide a fuller explanation of the literature and relevant physiology: introduction and overview; human milk reference data; intakes of water, protein, energy, lipid, carbohydrate, electrolytes, minerals, trace elements, water soluble vitamins, and fat soluble vitamins; feeding mode including mineral enteral feeding, feed advancement, management of gastric residuals, gastric tube placement and bolus or continuous feeding; growth; breastmilk buccal colostrum, donor human milk, and risks of cytomegalovirus infection; hydrolyzed protein and osmolality; supplemental bionutrients; and use of breastmilk fortifier.

CONCLUSIONS

We provide updated ESPGHAN CoN consensus-based conclusions and recommendations on nutrient intakes and nutritional management for preterm infants.

Probiotic Use in Preterm Neonates: A Review and Bibliometric Analysis

Background: Necrotizing enterocolitis (NEC) is a major health burden in peterm neonates with mortality rates between 21% and 50%. Prophylaxis is of primary importance as early diagnosis is hindered by the lack of specific signs and laboratory markers. Although probiotics have been routinely used for NEC prophylaxis in neonatal intensive care units around the world, clinical trials provide contradictory data, which fuels an ongoing debate about their efficacy and safety.

Aims: To perform a review and bibliometric analysis on available clinical trials and case reports data on the safety and efficacy of probiotics in preterm neonates and identify relevant publication trends and patterns.

Methods: A bibliometric search for publications on the topic was performed in the Web of Science Core Collection database and the resulting records analyzed in bibliometrix package in R.

Results: Trends in publication activity, historical direct citation network relationships and keyword co-ocurrences were discussed in the context of the most recent therapeutic recommendations.

Conclusion: We took a round view of the potential drawbacks to probiotic use in preterm infants and their possible solutions.

Comparison of the Bifidogenic Effects of Goat and Cow Milk-Based Infant Formulas to Human Breast Milk in an in vitro Gut Model for 3-Month-Old Infants

Human milk contains prebiotic components, such as human milk oligosaccharides (HMOs), which stimulate the growth of specific members of the infant gut microbiota (e.g., Bifidobacteria). Plant-based or synthetic oligosaccharides are often added to infant formulas to simulate the bifidogenic effect of HMOs. Cow milk, the most common source of protein in infant formula, and goat milk, used increasingly in the manufacture of infant formula, contain naturally-occurring prebiotics. This study compared the upper gastrointestinal digestion and subsequent colonic fermentation of human milk vs. goat and cow milk-based infant formulas (goat IF and cow IF, respectively), without additional oligosaccharides using an in vitro model for 3-month-old infants based on the Simulator of the Human Intestinal Microbial Ecosystem (SHIME®). First, a dialysis approach using 3.5 kDa membranes was demonstrated to simulate small intestinal absorption of carbohydrates in conditions similar to those in vivo. During the in vitro digestion experiment, oligosaccharides were detected in human milk and goat IF but barely detected in the cow IF. Further, all three milk matrices decreased colonic pH by boosting acetate, lactate, and propionate production, which related to increased abundances of acetate/lactate-producing Bifidobacteriaceae for human milk (+25.7%) and especially goat IF (33.8%) and cow IF (37.7%). Only cow IF stimulated butyrate production which correlated with an increase in Lachnospiraceae and Clostridiaceae. Finally, Enterobacteriaceae and Acidaminococcaceae also increased with all three milk matrices, while production of proteolytic metabolites (branched-chain fatty acids) was only detected for the cow IF. Overall, goat and cow milk-based formulas without added oligosaccharides impacted gut microbial activity and composition similarly to human milk. This suggests that even without supplementation of formula with oligosaccharides, whole goat milk, whole cow milk and cow milk ingredients already supply compounds in formulas that exert beneficial bifidogenic effects. Further clinical research is warranted to elucidate the effect of whole goat milk-based formulas on the infant gut microbiome.

Modelling intestinal glucose absorption in premature infants using continuous glucose monitoring data

BACKGROUND

Model-based glycaemic control protocols have shown promise in neonatal intensive care units (NICUs) for reducing both hyperglycaemia and insulin-therapy driven hypoglycaemia. However, current models for the appearance of glucose from enteral feeding are based on values from adult intensive care cohorts. This study aims to determine enteral glucose appearance model parameters more reflective of premature infant physiology.

METHODS

Peaks in CGM data associated with enteral milk feeds in preterm and term infants are used to fit a two compartment gut model. The first compartment describes glucose in the stomach, and the half life of gastric emptying is estimated as 20 min from literature. The second compartment describes glucose in the small intestine, and absorption of glucose into the blood is fit to CGM data. Two infant cohorts from two NICUs are used, and results are compared to appearances derived from data in highly controlled studies in literature.

RESULTS

The average half life across all infants for glucose absorption from the gut to the blood was 50 min. This result was slightly slower than, but of similar magnitude to, results derived from literature. No trends were found with gestational or postnatal age. Breast milk fed infants were found to have a higher absorption constant than formula fed infants, a result which may reflect known differences in gastric emptying for different feed types.

CONCLUSIONS

This paper presents a methodology for estimation of glucose appearance due to enteral feeding, and model parameters suitable for a NICU model-based glycaemic control context.

Probiotics and necrotizing enterocolitis

One of the most controversial areas in neonatology is whether probiotics should be provided routinely to preterm infants to prevent necrotizing enterocolitis (NEC). This review provides the reader with a brief overview of NEC and current concepts of its pathophysiology, discusses the microbial ecology of the intestine in preterm infants and factors that may lead to a "dysbiosis", summarizes studies of probiotics in preterm infants, elaborates on the need for regulation in this area, and discusses alternatives to probiotics and what is the future for the prevention of NEC.

Fecal short-chain fatty acids of very-low-birth-weight preterm infants fed expressed breast milk or formula

OBJECTIVES

In preterm infants, the metabolic responses of gastrointestinal (GI) bacteria to different diets are poorly understood despite the possible effects on GI health. Therefore, we tested the hypothesis that diet influences bacterial metabolism by measuring short-chain fatty acids (SCFAs) in stool samples from very-low-birth-weight (VLBW) preterm infants without GI disorder as surrogate biomarkers of bacterial metabolism.

METHODS

Ion chromatography was used to measure fecal SCFAs (acetate, formate, propionate, butyrate, and isobutyrate), lactate, and chloride in fresh stool samples collected from 32 preterm infants (without major congenital anomalies, GI disorders, or a recent history of antibiotic administration and on full feed of either expressed maternal breast milk [EBM; n = 13] or a formula for preterm infants [Similac Special Care Formula; preterm formula, PTF; n = 19]).

RESULTS

The mean birth weight was 972 g, the mean gestational age was 27 weeks, and the mean postnatal age at first stool sample was 36 days. When adjusted for gestational age, the stools of EBM infants had higher concentrations (micromoles per gram of stool) of total SCFA (128 vs 68; P = 0.002), acetate (41 vs 13; P = 0.005), propionate (15.1 vs 4.4; P = 0.003), and chloride (21,814 vs 10,652; P = 0.02). Interactions between postnatal age and diet were detected for lactate (P = 0.05), propionate (P = 0.03), and butyrate (P = 0.03).

CONCLUSIONS

Diets fed to VLBW preterm infants influence fecal SCFA profiles, and hence the metabolism of the GI bacteria, and potentially the health of preterm infants. The responses of bacterial metabolism to diet are influenced with postnatal age and gestational age at birth.

Physiologic underpinnings for clinical problems in moderately preterm and late preterm infants

This article highlights some of the important developmental characteristics that underpin common problems seen in moderate and late preterm infants. Preterm birth is associated with an increased prevalence of clinical problems caused by functional immaturities in a wide variety of organ systems, acquired problems, and problems associated with inadequate monitoring and/or follow-up plans. There are variations in the degree of maturation among infants of similar gestational ages because the developmental process is nonlinear. Therefore, different organ systems mature at rates and trajectories that are specific to their functions. A better understanding of these principles can help guide optimal treatment strategies.

Companion animals symposium: development of the mammalian gastrointestinal tract, the resident microbiota, and the role of diet in early life

Mammalian gastrointestinal (GI) development is guided by genetic determinants established during the evolution of mammals and matched to the natural diet and environment. Coevolution of the host GI tract (GIT) and the resident bacteria has resulted in commensal relationships that are species and even individual specific. The interactions between the host and the GI bacteria are 2-way and of particular importance during the neonatal period, when the GIT needs to adapt rapidly to the external environment, begin processing of oral foods, and acquire the ability to differentiate between and react appropriately to colonizing commensal and potentially pathogenic bacteria. During this crucial period of life, the patterns of gene expression that determine GI structural and functional development are modulated by the bacteria colonizing the previously sterile GIT of fetuses. The types and amounts of dietary inputs after birth influence GI development, species composition, and metabolic characteristics of the resident bacteria, and the interactions that occur between the bacteria and the host. This review provides overviews of the age-related changes in GIT functions, the resident bacteria, and diet, and describes how interactions among these 3 factors influence the health and nutrition of neonates and can have lifelong consequences. Necrotizing enterocolitis is a common GI inflammatory disorder in preterm infants and is provided as an example of interactions that go awry. Other enteric diseases are common in all newborn mammals, and an understanding of the above interactions will enhance efforts to support neonatal health for infants and for farm and companion animals.

Clinical issues in the management of late preterm infants

Prematurity is defined as birth before 37 weeks of gestation and is the major determinant of morbidity and mortality in newborns. The gestational ages known as near term or late preterm represent about 75% of preterm births and are the fastest growing subgroups of premature infants. These infants range in gestational age from 34 0/7 to 36 6/7 weeks and are at greater risk of morbidity, such as respiratory complications, temperature instability, hypoglycemia, kernicterus, feeding problems, neonatal intensive care unit admissions, and adverse neurological sequelae when compared with term infants. Long-term neurological and school-age outcomes of late preterm infants are concerns of major public health importance because even a minor increase in the rate of neurological disability and scholastic failure in this group can have a huge impact on the health care and educational systems. There is an urgent need to educate health care providers and parents about the vulnerability of late preterm infants, who are in need of diligent monitoring and care during the initial hospital stay and a comprehensive follow-up plan for post neonatal and long-term evaluations. Clinicians involved in the day-to-day care of late preterm infants, as well as those developing guidelines and recommendations, would benefit from having a clear understanding of the potential differences in risks faced by these infants, compared with their more mature counterparts.

How do pharmacists manage acute diarrhoea in an 8-month-old baby? A simulated client study

Objectives

Community pharmacists claim a role in health care based on their added value as counsellors and providers of pharmaceutical care. The aim of this study was to assess to what extent they fulfil this role with respect to the management of acute diarrhoea in an 8-month-old baby.

Methods

In February 2008, two female simulated clients of 55 and 35 years old visited 101 Belgian pharmacies. Both entered the pharmacy and said: ‘I'm here for my grandchild/my sister's baby. She has diarrhoea.’ They only provided more information if the pharmacist asked for it. All the questions and the verbal advice provided by the pharmacist were audio-recorded and the suggested medicines were registered.

Key findings

One pharmacist did not ask any questions. All the other pharmacists asked the age of the child, 19% asked how long the symptoms had been on-going, 27% asked whether the baby had a fever and 24% inquired about vomiting. Seventy-five per cent of the pharmacists emphasized the importance of sufficient fluid intake and/or the risk of dehydration, while 4% described how to recognize such dehydration symptoms. Oral rehydration solution was suggested by 30% of the pharmacists, while 86% suggested the yeast probiotic Saccharomyces boulardii. Of the 28% spontaneously giving dietary advice, no-one said that normal feeding should restart ‘as soon as possible’. Thirty-one per cent advised consulting a doctor, either immediately or in the case of the symptoms not improving after a while.

Conclusions

Apart from inquiring about the child's age, the majority of pharmacists asked too few questions to be able to analyse the situation properly. Ample information was provided on the risk of dehydration, but counselling on the suggested medicines was insufficient.

Carbohydrate maldigestion induces necrotizing enterocolitis in preterm pigs

Necrotizing enterocolitis (NEC) remains the most severe gastrointestinal disorder in preterm infants. It is associated with the initiation of enteral nutrition and may be related to immature carbohydrate digestive capacity. We tested the hypothesis that a formula containing maltodextrin vs. a formula containing lactose as the principal source of carbohydrate would predispose preterm pigs to a higher NEC incidence. Cesarean-derived preterm pigs were given total parenteral nutrition for 48 h followed by total enteral nutrition with a lactose-based (n = 11) or maltodextrin-based (n = 11) formula for 36 h. A higher incidence (91% vs. 27%) and severity (score of 3.3 vs. 1.8) of NEC were observed in the maltodextrin than in the lactose group. This higher incidence of NEC in the maltodextrin group was associated with significantly lower activities of lactase, maltase, and aminopeptidase; reduced villus height; transiently reduced in vivo aldohexose uptake; and reduced ex vivo aldohexose uptake capacity in the middle region of the small intestine. Bacterial diversity was low for both diets, but alterations in bacterial composition and luminal concentrations of short-chain fatty acids were observed in the maltodextrin group. In a second study, we quantified net portal absorption of aldohexoses (glucose and galactose) during acute jejunal infusion of a maltodextrin- or a lactose-based formula (n = 8) into preterm pigs. We found lower net portal aldohexose absorption (4% vs. 42%) and greater intestinal recovery of undigested carbohydrate (68% vs. 27%) in pigs acutely perfused with the maltodextrin-based formula than those perfused with the lactose-based formula. The higher digestibility of the lactose than the maltodextrin in the formulas can be attributed to a 5- to 20-fold higher hydrolytic activity of tissue-specific lactase than maltases. We conclude that carbohydrate maldigestion is sufficient to increase the incidence and severity of NEC in preterm pigs.

Set up of a newin vitromodel to study dietary fructans fermentation in formula-fed babies

A newin vitrofermentation model with immobilised infant faecal microbiota simulating the proximal colon of a formula-fed baby was developed and used to test the effects of known prebiotic fructans. Intestinal fermentation, based on a previously developed colonic fermentation model, using a new feeding medium simulating a formula-fed infant ileal chyme, was carried out for seventy-one consecutive days divided into four stabilisation periods intercalated with four prebiotic treatment periods. At the end of the first stabilisation period, total bacterial concentration in colonised beads and in faecal sample was similar, metabolite concentrations returned to stabilisation values after each treatment period. As expected, the four prebiotic treatments significantly increased the bifidobacterial populations, whereas they decreased bacteroides and clostridia. No difference was observed in the prebiotic effect of these substrates selected. The treatments significantly increased total production of SCFA and decreased ammonia compared to stabilisation periods. Long-term stability of the system together with the reproducibility of the known prebiotic effects highlights the potential of the present model to quantify and compare the effects of different substrates in a formula-fed infant microbiota within the same fermentation experiment.

Short-chain fatty acids: ready for prime time?

The concept of colonic health has become a major target for the development of functional foods such as probiotics, prebiotics, and synbiotics. These bioactive agents have a profound effect on the composition of the microflora, as well as on the physiology of the colon, and display distinct health benefits. Dietary carbohydrates escaping digestion/absorption in the small bowel and prebiotics undergo fermentation in the colon and give rise to short-chain fatty acids (SCFA). As the main anions of the colon and the major source of energy for colonocytes, SCFA are rapidly absorbed by nonionic diffusion mostly but also by active transport mediated by a sodium-coupled transporter, thereby fostering the absorption of sodium and water. SCFA in general and butyrate in particular enhance the growth of lactobacilli and bifidobacteria and play a central role on the physiology and metabolism of the colon. The effect of prebiotics on cell proliferation, differentiation, apoptosis, mucin production, immune function, mineral absorption, lipid metabolism, and gastrointestinal (GI) peptides has been well documented experimentally. These effects seem to be largely mediated by SCFA, but evidence from human studies remains inconsistent. The food industry is making a leap of faith in their efforts to commercialize prebiotics and exploit potential health benefits. The future lies with the design of studies to further explore basic mechanisms, and gene expression in particular, but emphasis should be placed on human intervention trials.

Optimizing care and outcome for late-preterm (near-term) infants: a summary of the workshop sponsored by the National Institute of Child Health and Human Development

In 2003, 12.3% of births in the United States were preterm (< 37 completed weeks of gestation). This represents a 31% increase in the preterm birth rate since 1981. The largest contribution to this increase was from births between 34 and 36 completed weeks of gestation (often called the "near term" but referred to as "late preterm" in this article). Compared with term infants, late-preterm infants have higher frequencies of respiratory distress, temperature instability, hypoglycemia, kernicterus, apnea, seizures, and feeding problems, as well as higher rates of rehospitalization. However, the magnitude of these morbidities at the national level and their public health impact have not been well studied. To address these issues, the National Institute of Child Health and Human Development of the National Institutes of Health invited a multidisciplinary team of experts to a workshop in July 2005 entitled "Optimizing Care and Outcome of the Near-Term Pregnancy and the Near-Term Newborn Infant." The participants discussed the definition and terminology, epidemiology, etiology, biology of maturation, clinical care, surveillance, and public health aspects of late-preterm infants. Knowledge gaps were identified, and research priorities were listed. This article provides a summary of the meeting.

Immobilization of infant fecal microbiota and utilization in an in vitro colonic fermentation model

Bacteria isolated from infant feces were immobilized in polysaccharide gel beads (2.5% gellan gum, 0.25% xanthan gum) using a two-phase dispersion process. A 52-day continuous culture was carried out in a single-stage chemostat containing precolonized beads and fed with a medium formulated to approximate the composition of infant chyme. Different dilution rates and pH conditions were tested to simulate the proximal (PCS), transverse (TCS), and distal (DCS) colons. Immobilization preserved all nine bacterial groups tested with survival rates between 3 and 56%. After 1 week fermentation, beads were highly colonized with all populations tested (excepted Staphylococcus spp. present in low numbers), which remained stable throughout the 7.5 weeks of fermentation, with variations below 1 log unit. However, free-cell populations in the circulating liquid medium, produced by immobilized cell growth, cell-release activity from gel beads, and free-cell growth, were altered considerably by culture conditions. Compared to the stabilization period, PCS was characterized by a considerable and rapid increase in Bifidobacterium spp. concentrations (7.4 to 9.6 log CFU/mL), whereas Bifidobacterium spp., Lactobacillus spp., and Clostridium spp. concentrations decreased and Staphylococcus spp. and coliforms increased during TCS and DCS. Under pseudo-steady-state conditions, the community structure developed in the chemostat reflected the relative proportions of viable bacterial numbers and metabolites generally encountered in infant feces. This work showed that a complex microbiota such as infant fecal bacteria can be immobilized and used in a continuous in vitro intestinal fermentation model to reproduce the high bacterial concentration and bacterial diversity of the feces inoculum, at least at the genera level, with a high stability during long-term experiment.

Enhanced weight gain in preterm infants receiving lactase-treated feeds: a randomized, double-blind, controlled trial

OBJECTIVE

To evaluate whether lactase-treated preterm feeds enhance weight gain and feeding tolerance in premature infants.

STUDY DESIGN

Prospective, double-blind, randomized, controlled trial involving 130 infants (26-34 weeks postconceptual age). The primary outcome variable was weight gain (g per day). Other outcome measures included gains in length and head circumference, biochemical indexes of nutritional status, feeding intolerance, and incidence of necrotizing enterocolitis.

RESULTS

On study day 10, weight gain (mean +/- SEM) of the treatment group was significantly greater (P <.05) than that of the control group (20.4 +/- 1.8 g/day vs 15.5 +/- 1.6 g/day). By study end, no significant difference in weight gain between treatment and control groups was observed. The difference in serum albumin level was significant at study day 14, with a value of 29.3 +/- 0.6 g/L in the treatment group compared with 27.1 +/- 0.4 g/L in the control group (P <.01). There were no significant differences in caloric intakes, length gain, head circumference gain, feeding intolerance, and incidence of necrotizing enterocolitis.

CONCLUSIONS

Weight gain may be enhanced during the period of low functional lactase activity of prematurity by addition of lactase to preterm feeds. No adverse effects on feeding tolerance resulted from this treatment.

Quantitation of colonic luminal synthesis of butyric acid in piglets

OBJECTIVES

Butyric acid, synthesized via bacterial fermentation in colonic lumen, may play an important role in the nutrition of the colonic mucosa. Since disaccharides, especially lactose, are the principal dietary carbohydrates during infancy, it is important to determine if their fermentation is associated with butyric acid synthesis. The objective of this paper is to describe a newly developed stable isotope method for quantifying butyric acid synthesis in the colonic lumen and to demonstrate its application during cecal infusions of lactose and lactulose in piglets.

METHODS

Nine piglets aged 21 to 30 days were studied during acute anesthesia. The C enrichment of butyric acid was monitored in the portal vein before and during a 120 minutes cecal infusion of [1- C]-butyric acid and either unlabeled lactose (N = 4) or lactulose (N = 5).

RESULTS

The luminal synthesis of BA (micromol x kg x min ) (Mean +/- S.D.) was respectively 1.5 +/- 0.9 and 1.2 +/- 0.6 during lactulose and lactose infusion.

CONCLUSIONS

This study provides new quantitative data on in vivo butyric acid production in the mammalian colon.

Nutrient requirements for preterm infant formulas

Achieving appropriate growth and nutrient accretion of preterm and low birth weight (LBW) infants is often difficult during hospitalization because of metabolic and gastrointestinal immaturity and other complicating medical conditions. Advances in the care of preterm-LBW infants, including improved nutrition, have reduced mortality rates for these infants from 9.6 to 6.2% from 1983 to 1997. The Food and Drug Administration (FDA) has responsibility for ensuring the safety and nutritional quality of infant formulas based on current scientific knowledge. Consequently, under FDA contract, an ad hoc Expert Panel was convened by the Life Sciences Research Office of the American Society for Nutritional Sciences to make recommendations for the nutrient content of formulas for preterm-LBW infants based on current scientific knowledge and expert opinion. Recommendations were developed from different criteria than that used for recommendations for term infant formula. To ensure nutrient adequacy, the Panel considered intrauterine accretion rate, organ development, factorial estimates of requirements, nutrient interactions and supplemental feeding studies. Consideration was also given to long-term developmental outcome. Some recommendations were based on current use in domestic preterm formula. Included were recommendations for nutrients not required in formula for term infants such as lactose and arginine. Recommendations, examples, and sample calculations were based on a 1000 g preterm infant consuming 120 kcal/kg and 150 mL/d of an 810 kcal/L formula. A summary of recommendations for energy and 45 nutrient components of enteral formulas for preterm-LBW infants are presented. Recommendations for five nutrient:nutrient ratios are also presented. In addition, critical areas for future research on the nutritional requirements specific for preterm-LBW infants are identified.

Human milk oligosaccharides are resistant to enzymatic hydrolysis in the upper gastrointestinal tract

BACKGROUND

Human milk oligosaccharides (HMOs) show a complexity and variety not found in milk of any other species. Although progress has been made in the past 3 decades with regard to identification and structural characterization of HMOs, not much is known about the physiologic functions of HMOs.

OBJECTIVE

As a prerequisite for biological activity in infant metabolism, HMOs have to resist enzymatic hydrolysis in the gastrointestinal tract. To assess the extent to which selected HMOs are hydrolyzed, we carried out in vitro digestion studies using enzyme preparations of human and porcine pancreas and intestinal brush border membranes (BBMs).

DESIGN

Fractions of HMOs, including structurally defined isolated oligosaccharides, were digested for up to 20 h with human pancreatic juice and BBMs prepared from human or porcine intestinal tissue samples. HMOs were incubated by using a porcine pancreatic homogenate and BBMs as enzyme sources. HMOs and digestion products were identified by mass spectrometry and anion-exchange chromatography. Additionally, free D-glucose, L-fucose, and N-acetylneuraminic acid were determined enzymatically.

RESULTS

Whereas maltodextrin (control) was rapidly and completely hydrolyzed, neutral and acidic HMOs showed a profound resistance against pancreatic juice and BBM hydrolases. However, cleavage of most of the HMOs was achieved by using a pancreatic homogenate containing intracellular, including lysosomal, enzymes in addition to secreted enzymes.

CONCLUSIONS

The results of this study strongly suggest that HMOs are not hydrolyzed by enzymes in the upper small intestine. Although intact HMOs may be absorbed, we postulate that a majority of HMOs reach the large intestine, where they serve as substrates for bacterial metabolism. Therefore, HMOs might be considered the soluble fiber fraction of human milk.