Gastric emptying in preterm infants

Protein ingredient quality of infant formulas impacts their structure and kinetics of proteolysis under in vitro dynamic digestion

Infant formula (IF) is a complex matrix requiring numerous ingredients and processing steps. The objective was to understand how the quality of protein ingredients impacts IF structure and, in turn, their kinetics of digestion. Four powdered IFs (A/B/C/D), based on commercial whey protein (WP) ingredients, with different protein denaturation levels and composition (A/B/C), and on caseins with different supramolecular organisations (C/D), were produced at a semi-industrial level after homogenization and spray-drying. Once reconstituted in water (13 %, wt/wt), the IF microstructure was analysed with asymmetrical flow field-flow fractionation coupled with multi-angle light scattering and differential refractometer, transmission electron microscopy and electrophoresis. The rehydrated IFs were subjected to simulated infant in vitro dynamic digestion (DIDGI®). Digesta were regularly sampled to follow structural changes (confocal microscopy, laser-light scattering) and proteolysis (OPA, SDS-PAGE, LC-MS/MS, cation-exchange chromatography). Before digestion, different microstructures were observed among IFs. IF-A, characterized by more denatured WPs, presented star-shaped mixed aggregates, with protein aggregates bounded to casein micelles, themselves adsorbed at the fat droplet interface. Non-micellar caseins, brought by non-micellar casein powder (IF-D) underwent rearrangement and aggregation at the interface of flocculated fat droplets, leading to a largely different microstructure of IF emulsion, with large aggregates of lipids and proteins. During digestion, IF-A more digested (degree of proteolysis + 16 %) at 180 min of intestinal phase than IF-C/D. The modification of the supramolecular organisation of caseins implied different kinetics of peptide release derived from caseins during the gastric phase (more abundant at G80 for IF-D). Bioactive peptide release kinetics were also different during digestion with IF-C presenting a maximal abundance for a large proportion of them. Overall, the present study highlights the importance of the structure and composition of the protein ingredients (WPs and caseins) selected for IF formulation on the final IF structure and, in turn, on proteolysis. Whether it has some physiological consequences remains to be investigated.

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.

Gastric function in diabetic gastroparesis assessed by ultrasound and scintigraphy

BACKGROUND

Gastroparesis is a severe diabetes complication characterized by delayed gastric emptying. We examined patients with symptoms of diabetic gastroparesis using gastric emptying scintigraphy and ultrasound drink test. The primary aim was to investigate how ultrasound could provide information about gastric motility features in diabetic gastroparesis.

MATERIAL AND METHODS

We prospectively included 58 patients with diabetes (48 type 1) with symptoms of gastroparesis and 30 healthy controls. Patients were examined with ultrasound of the stomach in a seated position after drinking 500 ml low-caloric meat soup, at the same time recording dyspeptic symptoms. The following day, they were examined with gastric emptying scintigraphy, defining gastroparesis as >10% retention after 4 h.

KEY RESULTS

We found motility disturbances in the proximal stomach measured by ultrasound in patients with diabetic gastroparesis. A linear mixed effects model including repeated ultrasound measurements revealed a slower decrease of the proximal stomach size in gastroparesis compared to healthy controls (p < 0.01), and the proximal diameter at 20 min was correlated to scintigraphy at 4 h (r = 0.510, p = 0.001). The antrum in patients with diabetic gastroparesis was twice as large compared to healthy controls (p = 0.009), and fasting antral size was correlated to gastric emptying scintigraphy (r = 0.329, p = 0.013). Both diabetes patients with and without gastroparesis had impaired accommodation (p = 0.011).

CONCLUSIONS AND INFERENCES

On ultrasound, we found delayed reduction of proximal stomach size and impaired accommodation after a liquid meal in patients with gastroparesis, emphasizing the role of the proximal stomach. Furthermore, we found antral distention in gastroparesis patients.

Review of paediatric gastrointestinal physiology relevant to the absorption of orally administered medicines

Despite much progress in regulations to improve paediatric drug development, there remains a significant need to develop better medications for children. For the design of oral dosage forms, a detailed understanding of the specific gastrointestinal (GI) conditions in children of different age categories and how they differ from GI conditions in adults is essential. Several review articles have been published addressing the ontogeny of GI characteristics, including luminal conditions in the GI tract of children. However, the data reported in most of these reviews are of limited quality because (1) information was cited from very old publications and sometimes low quality sources, (2) data gaps in the original data were filled with textbook knowledge, (3) data obtained on healthy and sick children were mixed, (4) average data obtained on groups of patients were mixed with data obtained on individual patients, and (5) results obtained using investigative techniques that may have altered the outcome of the respective studies were considered. Consequently, many of these reviews draw conclusions that may be incorrect. The aim of the present review was to provide a comprehensive and updated overview of the available original data on the ontogeny of GI luminal conditions relevant to oral drug absorption in the paediatric population. To this end, the PubMed and Web of Science metadatabases were searched for appropriate studies that examined age-related conditions in the oral cavity, esophagus, stomach, small intestine, and colon. Maturation was observed for several GI parameters, and corresponding data sets were identified for each paediatric age group. However, it also became clear that the ontogeny of several GI traits in the paediatric population is not yet known. The review article provides a robust and valuable data set for the development of paediatric in vitro and in silico biopharmaceutical tools to support the development of age-appropriate dosage forms. In addition, it provides important information on existing data gaps and should provide impetus for further systematic and well-designed in vivo studies on GI physiology in children of specific age groups in order to close existing knowledge gaps and to sustainably improve oral drug therapy in children.

Hypermagnesemia and feeding intolerance in preterm infants: a cohort study

BACKGROUND

Feeding intolerance (FI) is a common clinical problem in preterm infants often caused by some neonatal disorders and drugs, including antenatal exposure to magnesium sulfate (MgSO₄ ).

OBJECTIVE

To evaluate the association between hypermagnesemia at birth and FI in preterm infants during the first 72 hours of life.

METHOD

This was a cohort study conducted with preterm infants < 34 weeks of gestation. Infants presenting at least two of the following signs were considered as having FI: vomiting, abdominal distension, the need for continuous intermittent feeding, and delayed meconium passage. Hypermagnesemia was characterized by umbilical serum magnesium levels >2.5 mEq/l.

RESULTS

251 infants were evaluated. The median birth weight and gestational age were 1390 (IQR 1020 -1070) g and 31 (IQR 28-32) weeks, respectively. The FI rate was 17.5%. The exposure rate to MgSO₄ was similar in the tolerant and intolerant groups (53.1% x 63.6%, p=0.204), but hypermagnesemia was more frequent in the FI group (40.9% x 24.2%, p= 0.024). The univariate analysis showed that infants with hypermagnesemia were two-fold more likely to present FI (OR 2.16 95% CI 1.09-4.26). In the multiple logistic regression analysis, we found that hypermagnesemia was independently associated with FI (OR 2.51 - 95% CI 1.06-5.91), as well as maternal diabetes mellitus (OR 2.56 95% CI 1.07 - 6.14), SNAPPE-II (OR 1.051 95% CI 1.025-1.078), and brain hemorrhage (OR 3.61 95% CI 1.31 - 9.91).

CONCLUSION

In addition to other factors, hypermagnesemia at birth was independently associated with early feeding intolerance in preterm infants. This article is protected by copyright. All rights reserved.

Effect of different positions on gastric residuals in preterm infants initiating full enteral feeding

BACKGROUND

This study was conducted to determine the effect of feeding in different positions on the gastric residual volume after feeding in preterm infants who initiated full enteral feeding.

METHODS

This quasi-experimental study was conducted with the hypothesis that testing the right lateral position leads to less gastric residual than left lateral position and the prone position leads to less gastric residual than the supine position. The data were collected in four stages from 35 preterm infants. Initially, the infants were positioned in supine position and were fed. After feeding, the infant rested in the supine position for 3 h. The stomach content was aspirated, and the volume of gastric residual was measured at the 60th, 120th, and 180th min after feeding. These steps are repeated in order of in the right lateral, left lateral, and prone position. Total gastric residual volume and type of enteral feeding were evaluated.

RESULTS

There was no significant difference among the positions in terms of the volume of gastric residuals in the measurements made at 60th (P = 9.552), 120th (P = .505), and 180th min (P = .430). When the amount of decrease in the gastric residual volumes was a significant difference between all measurement times in right lateral and prone positions (P < .001).

CONCLUSION

Although no significant difference was determined between the positions, the smallest residual volumes were determined in the right lateral and prone positions. The amount of decrease in residual volume was significant in right lateral and prone positions.

Gastric Emptying and Intragastric Behavior of Breast Milk and Infant Formula in Lactating Mothers

BACKGROUND

When sufficient breast milk is not available, infant formula is often used as an alternative. As for digestion, gastric behavior of infant formula and breast milk have not been studied in detail.

OBJECTIVE

This study aimed to compare gastric emptying and intragastric behavior between breast milk and infant formula in vivo using MRI.

METHODS

In this randomized crossover study, 16 lactating mothers (age: 31.7 ± 2.9 y; time since giving birth: 9.3 ± 2 mo), underwent gastric MRI scans before and after consumption of 200 mL of infant formula or their own breast milk. MRI scans were performed after an overnight fast (baseline) and every 10 min up until 60 min following ingestion. Primary outcomes were gastric emptying measures and the secondary outcome was gastric layer volume over time. Differences between infant formula and breast milk in total gastric volume and layering volume were tested using linear mixed models.

RESULTS

Gastric emptying half-time was 5.1 min faster for breast milk than for infant formula (95% CI: -19.0 to 29.2) (n = 14). Within a subgroup (n = 12) with similar initial gastric volume (<20 mL difference), gastric emptying half-time was 20 min faster for breast milk (95% CI: 1.23-43.1). Top layer volume (n = 16) was 6.4 mL greater for infant formula than for breast milk (95% CI: 1.9-10.8). This effect is driven by t = 10 and t = 20 min postingestion.

CONCLUSIONS

When taking initial gastric volume into account, breast milk emptied faster than infant formula in women, which is in line with previous findings in infants. Infant formula showed a significantly larger top layer volume in the first 20 min after ingestion. MRI in adults may find application in studies assessing gastric behavior of infant formula.

The Physiologic Significance of Early Urinary Intestinal Fatty Acid Binding Protein Levels in Preterm Infants: A Prospective Cohort Study

Intestinal fatty acid binding protein (I-FABP) is released from mature enterocytes when cell membrane integrity is disrupted. This study aimed to prospectively investigate the physiologic significance of early urinary I-FABP and whether it might reflect intestinal compromise in preterm infants. We conducted a prospective cohort study of 100 preterm infants weighing <1250 g and collected serial urine samples at 12, 24, and 48 h after birth. The correlations between initial urinary I-FABP/urinary creatinine (creatinine_u) levels and associated factors were analyzed. Among 100 patients, 15 were diagnosed with meconium obstruction of prematurity, and five were diagnosed with necrotizing enterocolitis during the hospital stay. Early urinary I-FABP/creatinine_u levels were inversely correlated with both gestational age (Spearman’s rank correlation coefficient (Rs) −0.381, p < 0.01) and birth weight ((Rs) −0.424, p < 0.01). Early urinary I-FABP/creatinine_u levels were associated with cord pH ((Rs) −0.436, p < 0.01) and base excess ((Rs) −0.258, p = 0.021). There were significantly positive correlations between early urinary I-FABP/creatinine_u levels and the time to full enteral feeding in preterm infants without specific intestinal morbidities. Therefore, a more premature gut with acute perinatal ischemia is expected to exhibit increased I-FABP levels shortly after birth. Because of small sample size, further large-scale studies are needed.

25 Years of Research in Human Lactation: From Discovery to Translation

Researchers have recently called for human lactation research to be conceptualized as a biological framework where maternal and infant factors impacting human milk, in terms of composition, volume and energy content are studied along with relationships to infant growth, development and health. This approach allows for the development of evidence-based interventions that are more likely to support breastfeeding and lactation in pursuit of global breastfeeding goals. Here we summarize the seminal findings of our research programme using a biological systems approach traversing breast anatomy, milk secretion, physiology of milk removal with respect to breastfeeding and expression, milk composition and infant intake, and infant gastric emptying, culminating in the exploration of relationships with infant growth, development of body composition, and health. This approach has allowed the translation of the findings with respect to education, and clinical practice. It also sets a foundation for improved study design for future investigations in human lactation.

Understanding protein digestion in infants and the elderly: Current in vitro digestion models

The last decades have witnessed a surge of interest in the fate of dietary proteins during gastrointestinal (GI) digestion. Although several in vitro digestion models are available as alternatives to clinical experiments, most of them focus on the digestive conditions of healthy young adults. This study investigates the static/dynamic models used to simulate digestion in infants and the elderly and considers the related in vivo conditions. The in vitro digestive protocols targeting these two groups are summarized, and the challenges associated with the further development of in vitro digestion models are discussed. Static models rely on several factors (e.g., enzyme concentration, pH, reaction time, and rotation speed) to differentiate digestive conditions depending on age. Dynamic models can more accurately simulate the complex digestion process and allow the inclusion of further parameters (sequential secretion of digestive fluids, gradual changes in pH, peristaltic mixing, GI emptying, and the inoculation of luminal microbiota). In the case of infants, age or growth stage clarification and the differentiation of digestive protocols between full-term and preterm infants are required, whereas protocols dealing with various health statuses are required in the case of the elderly, as this group is prone to oral cavity and GI function deterioration.

Ultrasound imaging for assessing functions of the GI tract

OBJECTIVE

In the following review we outline how ultrasound can be used to measure physiological processes in the gastrointestinal tract.

APPROACH

We have investigated the potential of ultrasound in assessing gastrointestinal physiology including original research regarding both basic methodology and clinical applications.

MAIN RESULTS

Our main findings show the use of ultrasound to study esophageal motility, measure volume and contractility of the stomach, assess motility, wall thickness, and perfusion of the small bowel, and evaluate wall vascularization and diameters of the large bowel.

SIGNIFICANCE

Ultrasound is a widely accessible technology that can be used for both scientific and clinical purposes. Being radiation-free and user friendly, the examination can be frequently repeated enabling longitudinal studies. Furthermore, it does not influence normal GI physiology, thus being useful to estimate motility and subtle changes in physiology. Accordingly, ultrasound scanning and physiological measurements may make a big difference for the scientist and the doctor; and for the patients who receive an efficient work-up.

Are Faba Bean and Pea Proteins Potential Whey Protein Substitutes in Infant Formulas? An In Vitro Dynamic Digestion Approach

Infant formulas (IFs) are used as substitutes for human milk and are mostly based on cow milk proteins. For sustainability reasons, animal protein alternatives in food are increasingly being considered, as plant proteins offer interesting nutritional and functional benefits for the development of innovative IFs. This study aimed to assess how a partial substitution (50%) of dairy proteins with faba bean and pea proteins influenced the digestibility of IFs under simulated dynamic in vitro digestion, which were set up to mimic infant digestion. Pea- and faba bean-based IFs (PIF and FIF, respectively) have led to a faster aggregation than the reference milk-based IF (RIF) in the gastric compartment; that did not affect the digesta microstructure at the end of digestion. The extent of proteolysis was estimated via the hydrolysis degree, which was the highest for FIF (73%) and the lowest for RIF (50%). Finally, it was apparent that in vitro protein digestibility and protein digestibility-corrected amino acid score (PDCAAS)-like scores were similar for RIF and FIF (90% digestibility; 75% PDCAAS), but lower for PIF (75%; 67%). Therefore, this study confirms that faba bean proteins could be a good candidate for partial substitution of whey proteins in IFs from a nutritional point of view, provided that these in vitro results are confirmed in vivo.

Ultrasound assessment of gastric emptying time in preterm infants: A prospective observational study

BACKGROUND

In paediatric anaesthesia, pre-operative fasting should be short to prevent discomfort, hunger, thirst and metabolic disorders. Current European guidelines recommend pre-operative fasting times of 4 h for breast milk and 6 h for formula milk in infants, whereas some national guidelines allow both until 4 h before anaesthesia.

OBJECTIVE

We evaluated the gastric emptying times of preterm infants after breast milk and formula milk, hypothesising that the mean gastric emptying time would be less than 4 h.

DESIGN

A prospective, observational, noninterventional cohort study.

SETTING

Neonatal ICU of a university hospital from August to September 2017.

PATIENTS

Twenty-two infants with a postmenstrual mean ± SD (range) age of 35 ± 2 (32 to 40) weeks were included. Based on their prescription plan, 10 infants received breast milk and 12 received formula milk with a total volume of 50 ± 16 (24 to 70) ml.

INTERVENTIONS

Gastric emptying was examined by sonographic measurements of the gastric antral area (GAA) before (FT0) and hourly after breast milk or formula milk feeding (FT1 to FT3).

MAIN OUTCOME MEASURES

Estimated gastric emptying time after enteral feeding with breast milk and formula milk in preterm infants.

RESULTS

The GAA of the preterm infants initially increased and subsequently decreased after feeding. GAA correlated significantly with fasting time (r = -0.53, P < 0.0001). At FT3 [199 ± 16 (175 to 225) min], GAA was 0.57 (0.42 to 0.91) cm and showed no difference compared with FT0. Using a linear regression model, the calculated mean gastric emptying time was 218 min.

CONCLUSION

The study shows that the mean gastric emptying time after enteral feeding with breast milk and formula milk is less than 4 h in preterm infants. These results support our current national fasting regimen of 4 h for any milk composition in infants before anaesthesia.

TRIAL REGISTRATION

German registry of clinical studies (DRKS-ID: DRKS 00013893).

Protein hydrolysate versus standard formula for preterm infants

BACKGROUND

When human milk is not available for feeding preterm infants, protein hydrolysate, rather than standard cow's milk formulas (with intact proteins), is often used because it is perceived as being tolerated better and less likely to lead to complications. However, protein hydrolysate formulas are more expensive than standard formulas, and concern exists that their use in practice is not supported by high-quality evidence.

OBJECTIVES

To assess the effects of feeding preterm infants hydrolysed formula (vs standard cow's milk formula) on risk of feed intolerance, necrotising enterocolitis, and other morbidity and mortality.

SEARCH METHODS

We used the standard Cochrane Neonatal search strategy including electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 1), in the Cochrane Library; Ovid MEDLINE (1966 to 28 January 2019); Ovid Embase (1980 to 28 January 2019); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (28 January 2019), as well as conference proceedings and previous reviews.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials that compared feeding preterm infants protein hydrolysate versus standard (non-hydrolysed) cow's milk formula.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial eligibility and risk of bias and extracted data independently. We analysed treatment effects as described in the individual trials and reported risk ratios and risk differences for dichotomous data, and mean differences for continuous data, with respective 95% confidence intervals (CIs). We used a fixed-effect model in meta-analyses and explored potential causes of heterogeneity in sensitivity analyses. We assessed quality of evidence at the outcome level using the GRADE approach.

MAIN RESULTS

We identified 11 trials for inclusion in the review. All trials were small (total participants 665) and had various methodological limitations including uncertainty about methods to ensure allocation concealment and blinding. Most participants were clinically stable preterm infants of less than about 34 weeks' gestational age or with birth weight less than about 1750 g. Fewer participants were extremely preterm, extremely low birth weight, or growth restricted. Most trials found no effects on feed intolerance, assessed variously as mean pre-feed gastric residual volume, incidence of abdominal distension or other gastrointestinal signs of concern, or time taken to achieve full enteral feeds (meta-analysis was limited because studies used different measures). Meta-analysis showed no effect on the risk of necrotising enterocolitis (typical risk ratio 1.10, 95% CI 0.36 to 3.34; risk difference 0.00, 95% CI -0.03 to 0.04; 5 trials, 385 infants) (low-certainty evidence; downgraded for imprecision and design weaknesses).

AUTHORS' CONCLUSIONS

The identified trials provide only low-certainty evidence about the effects of feeding preterm infants protein hydrolysate versus standard formula. Existing data do not support conclusions that feeding protein hydrolysate affects the risk of feed intolerance or necrotising enterocolitis. Additional large, pragmatic trials are needed to provide more reliable and precise estimates of effectiveness and cost-effectiveness.

Banked preterm versus banked term human milk to promote growth and development in very low birth weight infants

BACKGROUND

Human milk banking has been available in many countries for the last three decades. The milk provided from milk banking is predominantly term breast milk, but some milk banks provide preterm breast milk. There are a number of differences between donor term and donor preterm human milk.

OBJECTIVES

To determine the effect of banked donor preterm milk compared with banked donor term milk regarding growth and developmental outcomes in very low birth weight infants (infants weighing less than 1500 grams).

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 7), MEDLINE via PubMed (1966 to 23 October 2018), Embase (1980 to 23 October 2018), and CINAHL (1982 to 23 October 2018). We also searched clinical trial databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing banked donor preterm milk with banked donor term milk regarding growth and developmental outcomes in very low birth weight infants DATA COLLECTION AND ANALYSIS: We planned to perform assessment of methodology regarding blinding of randomisation, intervention and outcome measurements as well as completeness of follow-up. We planned to evaluate treatment effect using a fixed-effect model using relative risk (RR), relative risk reduction, risk difference (RD) and number needed to treat for an additional beneficial outcome (NNTB) or the number needed to treat for an additional harmful outcome (NNTH) for categorical data; and using mean, standard deviation and weighted mean difference (WMD) for continuous data. We planned to use the GRADE approach to assess the quality of evidence.

MAIN RESULTS

No studies met the inclusion criteria.

AUTHORS' CONCLUSIONS

We found no evidence to support or refute the effect of banked donor preterm milk compared to banked term milk regarding growth and developmental outcomes in very low birth weight infants.

Peptidomics Analysis of Milk Protein-Derived Peptides Released over Time in the Preterm Infant Stomach

Over the course of milk digestion, native milk proteases and infant digestive proteases fragment intact proteins into peptides with potential bioactivity. This study investigated the release of peptides over 3 h of gastric digestion in 14 preterm infant sample sets. The peptide content was extracted and analyzed from milk and gastric samples via Orbitrap tandem mass spectrometry. The relative ion intensity (abundance) and count of peptides in each sample were compared over time and between infants fed milk fortified with bovine milk fortifier and infants fed unfortified milk. Bioactivity of the identified peptides was predicted by sequence homology to known bioactive milk peptides. Both total and bioactive peptide abundance and count continuously increased over 3 h of gastric digestion. After accounting for infant weight, length, and postconceptual age, fortification of milk limited the release of peptides from human milk proteins. Peptides that survived further gastric digestion after their initial release were structurally more similar to bioactive peptides than nonsurviving peptides. This work is the first to provide a comprehensive profile of milk peptides released during gastric digestion over time, which is an essential step in determining which peptides are most likely to be biologically relevant in the infant. Data are available via ProteomeXchange with identifier PXD012192.

Clinical presentation and therapeutic management of venous thrombosis in young children: a retrospective analysis

BACKGROUND

Venous thromboembolism (VTE) in young children is not well documented.

METHODS

Clinicians from 12 institutions retrospectively evaluated the presentation, therapeutic management, and outcome of VTE in children younger than 2 years seen in 2011-2016. Feasibility of recruiting these children in EINSTEIN-Jr. phase III, a randomized trial evaluating rivaroxaban versus standard anticoagulation for VTE, was assessed.

RESULTS

We identified 346 children with VTE, of whom 227 (65.6%) had central venous catheter-related thrombosis (CVC-VTE), 119 (34.4%) had non-CVC-VTE, and 156 (45.1%) were younger than 1 month. Of the 309 children who received anticoagulant therapy, 86 (27.8%) had a short duration of therapy (i.e. < 6 weeks for CVC-VTE and < 3 months for non-CVC-VTE) and 17 (5.5%) had recurrent VTE during anticoagulation (n = 8, 2.6%) or shortly after its discontinuation (n = 9, 2.9%). A total of 37 (10.7%) children did not receive anticoagulant therapy and 4 (10.5%) had recurrent VTE.The average number of children aged < 0.5 years and 0.5-2 years who would have been considered for enrolment in EINSTEIN-Jr is approximately 1.0 and 0.9 per year per site, respectively.

CONCLUSIONS

Young children with VTE most commonly have CVC-VTE and approximately one-tenth and one-fourth received no or only short durations of anticoagulant therapy, respectively. Recurrent VTE rates without anticoagulation, during anticoagulation or shortly after its discontinuation seem comparable to those observed in adults. Short and flexible treatment durations could potentially increase recruitment in EINSTEIN-Jr. phase III.

Hydrogen peroxide promotes gastric motility in the newborn rat

BACKGROUND

When compared with infant formula, human milk enhances gastric emptying in preterm infants. Hydrogen peroxide (H₂O₂) is present in large quantities in human milk that has an antimicrobial role for the mother and infant. In vitro adult rat studies suggest that H₂O₂ facilitates gastric motor contraction. Hypothesizing that H₂O₂ enhances gastric motility, we investigated its effects on the newborn rat stomach tissue.

METHODS

Rat newborn and adult gastric fundic segments, or their smooth muscle cells, were used to evaluate the muscle response to H₂O₂ exposure. Tissue expression of Rho kinase 2 (ROCK-2; Western blot), its catalase activity, and H₂O₂ content (Amplex Red) were measured. H₂O₂ gastric mucosal diffusion was evaluated with Ussing chambers.

RESULTS

In both newborn and adult rats, H₂O₂ induced gastric muscle contraction and this response was attenuated by pre-incubation with the antioxidant melatonin. H₂O₂ passively diffused across the gastric mucosa. Its effect on the muscle was modulated via ROCK-2 activation and inhibited by melatonin.

CONCLUSION

H₂O₂, at a concentration similar to that of human milk, promotes gastric motility in the rat. To the extent that the present findings can be clinically extrapolated, the human milk H₂O₂ content may enhance gastric emptying in neonates.

Biopharmaceutical considerations in paediatrics with a view to the evaluation of orally administered drug products - a PEARRL review

OBJECTIVES

In this review, the current biopharmaceutical approaches for evaluation of oral formulation performance in paediatrics are discussed.

KEY FINDINGS

The paediatric gastrointestinal (GI) tract undergoes numerous morphological and physiological changes throughout its development and growth. Some physiological parameters are yet to be investigated, limiting the use of the existing in vitro biopharmaceutical tools to predict the in vivo performance of paediatric formulations. Meals and frequencies of their administration evolve during childhood and affect oral drug absorption. Furthermore, the establishment of a paediatric Biopharmaceutics Classification System (pBCS), based on the adult Biopharmaceutics Classification System (BCS), requires criteria adjustments. The usefulness of computational simulation and modeling for extrapolation of adult data to paediatrics has been confirmed as a tool for predicting drug formulation performance. Despite the great number of successful physiologically based pharmacokinetic models to simulate drug disposition, the simulation of drug absorption from the GI tract is a complicating issue in paediatric populations.

SUMMARY

The biopharmaceutics tools for investigation of oral drug absorption in paediatrics need further development, refinement and validation. A combination of in vitro and in silico methods could compensate for the uncertainties accompanying each method on its own.

Protein hydrolysate versus standard formula for preterm infants

BACKGROUND

When human milk is not available for feeding preterm infants, protein hydrolysate rather than standard cow's milk formulas (with intact proteins) are often used because they are perceived as being tolerated better and less likely to lead to complications. However, protein hydrolysate formulas are more expensive than standard formulas, and concern exists that their use in practice is not supported by high-quality evidence.

OBJECTIVES

To assess the effect of feeding preterm infants with hydrolysed formula (versus standard cow's milk formulas) on the risk of feed intolerance, necrotising enterocolitis, and other morbidity and mortality in preterm infants.

SEARCH METHODS

We used the standard Cochrane Neonatal search strategy including electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 4), Ovid MEDLINE, Ovid Embase, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (to April 2017), as well as conference proceedings and previous reviews.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials that compared feeding preterm infants with protein hydrolysate versus standard (non-hydrolysed) cow's milk formula.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial eligibility and risk of bias and extracted data independently. We analysed treatment effects as described in the individual trials and reported risk ratios and risk differences for dichotomous data, and mean differences for continuous data, with respective 95% confidence intervals (CI). We used a fixed-effect model in meta-analyses and explored potential causes of heterogeneity in sensitivity analyses. We assessed quality of evidence at the outcome level using the GRADE approach.

MAIN RESULTS

We identified 11 trials for inclusion in the review. All trials were small (total participants 665) and had various methodological limitations including uncertainty about methods to ensure allocation concealment and blinding. Most participants were clinically stable preterm infants of gestational age less than about 34 weeks or birth weight less than about 1750 g. Fewer participants were extremely preterm, extremely low birth weight, or growth-restricted. Most trials found no effects on feed intolerance assessed variously as mean prefeed gastric residual volume, incidence of abdominal distention or other concerning gastrointestinal signs, or time taken to achieve full enteral feeds (meta-analysis was limited because studies used different measures). Meta-analysis found no effect on the risk of necrotising enterocolitis (typical risk ratio 1.10, 95% CI 0.36 to 3.34; risk difference 0.00, 95% CI -0.03 to 0.04; 5 trials, 385 infants) (low quality evidence; downgraded for imprecision and design weaknesses).

AUTHORS' CONCLUSIONS

The identified trials provide only low quality evidence about the effects of feeding preterm infants with protein hydrolysate versus standard formula. The existing data did not support conclusions that feeding with protein hydrolysate affects the risk of feed intolerance or necrotising enterocolitis. Further large, pragmatic trials are needed to provide more reliable and precise estimates of effectiveness and cost-effectiveness.

Impact of human milk pasteurization on gastric digestion in preterm infants: a randomized controlled trial

BACKGROUND

Holder pasteurization has been reported to modify human milk composition and structure by inactivating bile salt-stimulated lipase (BSSL) and partially denaturing some of its proteins, potentially affecting its subsequent digestion.

OBJECTIVE

We sought to determine the impact of human milk pasteurization on gastric digestion (particularly for proteins and lipids) in preterm infants who were fed their mothers' own milk either raw or pasteurized.

DESIGN

In a randomized controlled trial, 12 hospitalized tube-fed preterm infants were their own control group in comparing the gastric digestion of raw human milk (RHM) with pasteurized human milk (PHM). Over a 6-d sequence, gastric aspirates were collected 2 times/d before and after RHM or PHM ingestion. The impact of milk pasteurization digestive kinetics and disintegration was tested with the use of a general linear mixed model.

RESULTS

Despite inactivating BSSL, instantaneous lipolysis was not affected by pasteurization (mean ± SD at 90 min: 12.6% ± 4.7%; P > 0.05). Lipolysis occurred in milk before digestion and was higher for PHM than for RHM (mean ± SD: 3.2% ± 0.6% and 2.2% ± 0.8%, respectively; P < 0.001). Pasteurization enhanced the proteolysis of lactoferrin (P < 0.01) and reduced that of α-lactalbumin (only at 90 min) (P < 0.05). Strong emulsion destabilization was observed, with smaller aggregates and a higher specific surface for PHM (P < 0.05). Pasteurization did not affect gastric emptying (∼30-min half time) or pH (mean ± SD: 4.4 ± 0.8) at 90 min.

CONCLUSIONS

Overall, pasteurization had no impact on the gastric digestion of lipids and some proteins from human milk but did affect lactoferrin and α-lactalbumin proteolysis and emulsion disintegration. Freeze-thawing and pasteurization increased the milk lipolysis before digestion but did not affect gastric lipolysis. Possible consequences on intestinal digestion and associated nutritional outcomes were not considered in this study. This trial was registered at clinicaltrials.gov as NCT02112331.

In Vitro Model Simulating Gastro-Intestinal Digestion in the Pediatric Population (Neonates and Young Infants)

The focus on drug delivery for the pediatric population has been steadily increasing in the last decades. In terms of developing in vitro models simulating characteristics of the targeted pediatric population, with the purpose of predicting drug product performance after oral administration, it is important to simulate the gastro-intestinal conditions and processes the drug will encounter upon oral administration. When a drug is administered in the fed state, which is commonly the case for neonates, as they are typically fed every 3 h, the digestion of the milk will affect the composition of the fluid available for drug dissolution/solubilization. Therefore, in order to predict the solubilized amount of drug available for absorption, an in vitro model simulating digestion in the gastro-intestinal tract should be utilized. In order to simulate the digestion process and the drug solubilization taking place in vivo, the following aspects should be considered; physiologically relevant media, media volume, use of physiological enzymes in proper amounts, as well as correct pH and addition of relevant co-factors, e.g., bile salts and co-enzymes. Furthermore, physiological transit times and appropriate mixing should be considered and mimicked as close as possible. This paper presents a literature review on physiological factors relevant for digestion and drug solubilization in neonates. Based on the available literature data, a novel in vitro digestion model simulating digestion and drug solubilization in the neonate and young infant pediatric population (2 months old and younger) was designed.

Impact of pasteurization of human milk on preterm newborn in vitro digestion: Gastrointestinal disintegration, lipolysis and proteolysis

Human milk feeding is an important recommendation for preterm newborns considering their vulnerability and digestive immaturity. Holder pasteurization (62.5°C, 30min) applied in milk banks modifies its biological quality and its microstructure. We investigated the impact of pasteurization of preterm human milk on its gastrointestinal kinetics of lipolysis, proteolysis and structural disintegration. An in vitro dynamic system was set up to simulate the gastrointestinal digestion of preterm newborns. A pool of preterm human milk was digested as raw or after Holder pasteurization. Pasteurization impacted the microstructure of undigested human milk, its gastrointestinal disintegration and tended to limit the intestinal lipolysis. Furthermore, the gastrointestinal bioaccessibility of some fatty acids was decreased by pasteurization, while the intestinal bioaccessibility of some amino acids was selectively modulated. The impact of pasteurization on the digestion of human milk may have nutritional relevance in vivo and potentially modulates preterm development and growth.

Gastric Emptying and Curding of Pasteurized Donor Human Milk and Mother's Own Milk in Preterm Infants

We evaluated the effects of fortification and composition on gastric emptying and curding in un/fortified pairs of mother's own milk (MOM, n = 17) and pasteurized donor human milk (PDHM, n = 15) in preterm infants. Retained meal proportions (%) and curding were determined from sonography. Immediate and subsequent postprandial % were higher for PDHM (23%, P = 0.026; 15%, P = 0.006) and fortified meals (31.5%; 8.8%, both P < 0.001), whereas higher casein, whey, and lactose concentrations were associated with lower immediate postprandial % (all P < 0.006). Curding did not affect emptying. Influences of fortification, pasteurization, and differing breast milk compositions are small and unlikely implicated in preterm feeding intolerance.

Risk assessment for extending the Biopharmaceutics Classification System-based biowaiver of immediate release dosage forms of fluconazole in adults to the paediatric population

OBJECTIVES

The paediatric population undergoes developmental changes in gastric pH, gastric emptying, intestinal transit time, membrane permeability, protein binding, body water, distribution and metabolism. It is widely recognised that changes in these parameters may result in an alteration of the plasma profile and thus in key bioequivalence parameters such as Cmax (maximum plasma concentration of drug) and area under the plasma concentration vs time profile curve. The aim of this work is to assess the risk of extending the biowaiver for immediate release dosage formulations of fluconazole from the adult to the paediatric population.

METHODS AND KEY FINDINGS

Fluconazole exhibits good solubility and very rapid dissolution characteristics in various pH media. The absorption of fluconazole in children is known to be complete (over 90%) and not impaired by elevated pH, which is prevalent during the early days of life. Dose numbers calculated using body surface area are less than 1. Therefore, the risk to drug absorption due to differences in gastric pH, gastric emptying, intestinal transit, membrane permeability and metabolising enzymes between adults and children is considered low.

CONCLUSIONS

Thus, it can be safely concluded that fluconazole meets highly soluble and highly permeable criteria in the paediatric population and can be allocated to class 1 of the Biopharmaceutics Classification System (BCS) for this population as well as in adults. Additionally, fluconazole has an excellent safety profile in children, similar to that in adults. The BCS-based biowaiver claimed in adults can be safely extended to the paediatric population provided that the requirements in excipient selection and dissolution profile comparison using BCS-based dissolution conditions as stated in the biowaiver monograph for fluconazole immediate release dosage forms in adults are fulfilled.

Does age affect gastric emptying time? A model-based meta-analysis of data from premature neonates through to adults

Purpose. Gastric emptying (GE) is often reported to be slower and more irregular in premature neonates than in older children and adults. The aim of this study was to investigate the impact of age and other covariates on the rate of GE. Methods. The effect of age on the mean gastric residence times (MGRT) of liquid and solid food was assessed by analysing 49 published studies of 1457 individuals, aged from 28 weeks gestation to adults. The data were modelled using the nonlinear mixed‐effects approach within NONMEM version 7.2 (ICON, Dublin, Ireland), with evaluation of postnatal age, gestational age and meal type as covariates. A double Weibull function was selected as a suitable model since it could account for the typical biphasic nature of GE. Results. Age was not a significant covariate for GE but meal type was. Aqueous solutions were associated with the fastest emptying time (mean simulated gastric residence time of 45 min) and solid food was associated with the slowest (98 min). Conclusions. These findings challenge the assertion that GE is different in neonates, as compared with older children and adults due to age, and they reinforce the significance of food type in modulating GE. © 2015 The Authors. Biopharmaceutics & Drug Disposition Published by John Wiley & Sons Ltd.

Influences of breast milk composition on gastric emptying in preterm infants

OBJECTIVES

The aim of the present study was to determine whether specific biochemical and energy concentrations influence gastric emptying of unfortified and fortified mother's own milk (MOM) in stable preterm infants, and whether gastric emptying differs between feeds of unfortified MOM and feeds fortified with S-26 or FM 85 human milk fortifier (HMF) when infants are fed the same volume under similar conditions. Influences of infant gestation, age, and weight, and feed characteristics were also explored.

METHODS

Stomach volumes of 25 paired unfortified and fortified MOM feeds were monitored prefeed and postfeed delivery and at 30-minute intervals thereafter. For each feed, MOM samples were analyzed to determine concentrations of total protein, casein, whey, carbohydrate, lactose, fat, and energy. Fortified feed compositions were calculated by adding fortifier biochemical and energy concentrations to unfortified MOM concentrations. Ultrasound images were used to calculate infant stomach volumes. Statistical comparisons were made of paired stomach volume measurements.

RESULTS

Higher feed concentrations of casein were associated with faster gastric emptying during feed delivery (P = 0.007). When compared with unfortified MOM, S-26 fortified feeds emptied similarly, whereas FM 85 fortified feeds emptied more slowly both during feed delivery and during the postprandial period (P = 0.002, <0.001, respectively). Gastric emptying was slower for 2-hourly feeds compared with that for 3-hourly feeds (P = 0.003) and in supine position compared with that in prone (P = 0.001).

CONCLUSIONS

Breast milk composition influences gastric emptying in stable preterm infants, with feeds of higher casein concentration emptying faster during feeding than otherwise equivalent feeds, and FM 85 fortified MOM emptying more slowly than unfortified MOM.

Specificity of infant digestive conditions: some clues for developing relevant in vitro models

Digestion of nutrients is an essential function of the newborn infant gut to allow growth and development and understanding infant digestive function is essential to optimize nutrition and oral drug delivery. Ethical considerations prohibit invasive in vivo trials and as a consequence in vitro assays are often conducted. However, the choice of in vitro model parameters are not supported by an exhaustive analysis of the literature and do not mimic precisely the digestive conditions of the infant. This review contains a compilation of the studies which characterized the gastroduodenal conditions in full-term or preterm infants of variable postnatal age from birth up to six months. Important data about healthy full-term infants are reported. The enzymatic (type of enzymes and level of activity) and nonenzymatic (milk-based diet, frequency of feeding, bile salt concentrations) conditions of digestion in infants are shown to differ significantly from those in adults. In addition, the interindividual and developmental variability of the digestive conditions in infants is also highlighted.

Gastric residual evaluation in preterm neonates: a useful monitoring technique or a hindrance?

It is routine practice in most neonatal intensive care units to measure the volume and color of gastric residuals (GRs) prior to enteral bolus feedings in preterm very low birth weight infants. However, there is paucity of evidence supporting the routine use of this technique. Moreover, owing to the lack of uniform standards in the management of GRs, wide variations exist as to what constitutes significant GR volume, the importance of GR color and frequency of GR evaluation, and the color or volume standards that dictate discarding or returning GRs. The presence of large GR volumes or green-colored residuals prior to feeding often prompts subsequent feedings to be withheld or reduced because of possible necrotizing enterocolitis resulting in delays in enteral feeding. Cessation or delays in enteral feeding may result in extrauterine growth restriction, a known risk factor for poor neurodevelopmental and growth outcomes in preterm very low birth weight infants. Although some neonatal intensive care units are abandoning the practice of routine GR evaluation, little evidence exists to support the discontinuation or continuation of this practice. This review summarizes the current state of GR evaluation and underlines the need for a scientific basis to either support or refute the routine evaluation of GRs.

Repeatability of gastric volume measurements and intragastric content using ultrasound in preterm infants

OBJECTIVES

The aim of the present study was to determine whether serial gastric volumes and intragastric curding are repeatable within individual preterm infants when given sequential feeds of the same volume and composition. Infant and feeding characteristics that may influence differences in measured gastric volumes, echogenicity, and intragastric curding were also explored.

METHODS

Ultrasound images were used to calculate gastric volumes and to rate echogenicity and intragastric curding for 20 infants. A total of 29 paired feeds of the same volume and composition were monitored prefeed and postfeed and at 30-minute intervals thereafter. Statistical comparisons of paired gastric volume measurements and agreement between echogenicity and curding ratings were made for each time point. Analyses of factors that influence discrepancies between volume measurements and between curding ratings were performed.

RESULTS

Paired gastric volume measurements were repeatable (intraclass correlation coefficient [ICC] = 0.971, 0.938 < ICC < 0.987). Most (75%) discrepancies were <2 mL and increased over time, although volume differences were small. Overall moderate levels of consistency were observed for ratings of echogenicity (κ = 0.44), and curd presence (κ ≤ 0.65), density (κ = 0.41), and volume (κ = 0.47). Gastric emptying during feed delivery is influenced with infant positioning, fortification of breast milk, and feeding frequency.

CONCLUSIONS

For preterm infants serial gastric volumes are repeatable and ratings of intragastric echogenicity and curding are moderately consistent when fed milk of the same volume and composition. Ultrasound has the potential to further explore factors that influence gastric emptying in the preterm infant.

Body dirt or liquid gold? How the 'safety' of donated breastmilk is constructed for use in neonatal intensive care

When mothers of preterm infants are unable to produce sufficient volumes of breastmilk, neonatologists in many Western countries prescribe pasteurized donor breastmilk. Breastmilk has a paradoxical presence in the neonatal intensive care unit while it has therapeutic properties, it also has the potential to transmit disease. National health authorities and local neonatal intensive care unit policies each delimit the safety of donor milk by focusing on the presence or absence of pathogens. It is in this light that breastmilk from the human milk bank is both sought and legitimated to minimize safety concerns. This research uses data arising from an ethnographic study of two human milk banks and two neonatal intensive care units in the United States, and 73 interviews with milk donors, neonatal intensive care unit parents and clinicians. The primary research question framing the study was 'What are the underlying processes and practices that have enabled donor milk to be endorsed as a safe and legitimate feeding option in neonatal intensive care units?' This study is framed using three key principles of Latour's 'new critique', namely, adding to reality rather than debunking it, getting closer to data rather than turning away from fact and creating arenas in which to assemble. As a result, conceptions of donor milk's safety are expanded. This case study of donor milk demonstrates how Latour's new critique can inform science and technology studies approaches to the study of safety in health care.

Validation of ultrasound methods to monitor gastric volume changes in preterm infants

OBJECTIVES

The aim of this study was to validate 4 sonographic methods of estimating stomach volume for the purpose of monitoring changes in gastric volume over time and to describe the echogenic characteristics of milk feeds.

METHODS

Twenty-four infants were monitored during a single intragastric tube feed, with 2 ultrasound images of the entire stomach and an image of the antral cross-sectional area (ACSA) before, during, and after the feed. Raw measurements, 3 stomach volume calculations, and ACSA were tested for intra- and interrater agreement. Calculated stomach volumes and ACSA were compared with delivered feed volumes, and characteristics of stomach image echogenicity graded at each time point.

RESULTS

Spheroid calculation of stomach volume was the most reliable and valid measure of stomach volume. Fortified breast milk feeds were more echogenic than unfortified breast milk feeds. Residual stomach volumes (median 2.12 mL, range 0.59-9.27 mL) were identified in 18 of 24 infants.

CONCLUSIONS

Direct ultrasound stomach measurement (spheroid) will provide a useful research tool and a potential clinical tool for assessing gastric emptying and feeding intolerance in preterm infants.

Supplementing monosodium glutamate to partial enteral nutrition slows gastric emptying in preterm pigs(1-3)

Emerging evidence suggests that free glutamate may play a functional role in modulating gastroduodenal motor function. We hypothesized that supplementing monosodium glutamate (MSG) to partial enteral nutrition stimulates gastric emptying in preterm pigs. Ten-day-old preterm, parenterally fed pigs received partial enteral nutrition (25%) as milk-based formula supplemented with MSG at 0, 1.7, 3.0, and 4.3 times the basal protein-bound glutamate intake (468 mg·kg(-1)·d(-1)) from d 4 to 8 of life (n = 5-8). Whole-body respiratory calorimetry and (13)C-octanoic acid breath tests were performed on d 4, 6, and 8. Body weight gain, stomach and intestinal weights, and arterial plasma glutamate and glutamine concentrations were not different among the MSG groups. Arterial plasma glutamate concentrations were significantly higher at birth than after 8 d of partial enteral nutrition. Also at d 8, the significant portal-arterial concentration difference in plasma glutamate was substantial (∼500 μmol/L) among all treatment groups, suggesting that there was substantial net intestinal glutamate absorption in preterm pigs. MSG supplementation dose-dependently increased gastric emptying time and decreased breath (13)CO2 enrichments, (13)CO2 production, percentage of (13)CO2 recovery/h, and cumulative percentage recovery of (13)C-octanoic acid. Circulating glucagon-like peptide-2 (GLP-2) concentration was significantly increased by MSG but was not associated with an increase in intestinal mucosal growth. In contrast to our hypothesis, our results suggest that adding MSG to partial enteral nutrition slows the gastric emptying rate, which may be associated with an inhibitory effect of increased circulating GLP-2.

Associated morbidities to congenital diaphragmatic hernia and a relationship to human milk

The majority of what is known in the recent literature regarding human milk studies in the neonatal intensive care setting is specific to term and/or preterm infants (including very-low-birth-weight preterm infants). However, there is a lack of human milk and breastfeeding literature concerning infants with congenital anomalies, specifically infants diagnosed with congenital diaphragmatic hernia (CDH). By applying human milk research conducted among other populations of infants, this article highlights how human milk may have a significant impact on infants with CDH. Recent human milk studies are reviewed and then applied to the CDH population in regard to respiratory and gastrointestinal morbidities, as well as infection and length of stay. In addition, clinical implications of these relationships are discussed and suggestions for future research are presented.

Effect of breast milk on hospital costs and length of stay among very low-birth-weight infants in the NICU

PURPOSE

Care of the very low-birth-weight (VLBW) infant is associated with prolonged hospitalization and increased hospital costs. Specific complications of prematurity, including necrotizing enterocolitis (NEC), late-onset sepsis (LOS), and feeding intolerance, contribute to increased cost and length of hospitalization in this population. The provision of breast milk to VLBW infants has been associated with decreased incidence of NEC and LOS as well as fewer days required to achieve full enteral feedings. The purpose of this study was to determine the impact of breast milk on length of hospitalization and hospital costs among VLBW infants in the neonatal intensive care unit (NICU).

SUBJECTS

A total of 80 infants weighing less than 1500 g, born prior to 32 weeks' gestation and who remained in the home hospital until discharge.

DESIGN

This descriptive comparative study examined cost of hospitalization and length of stay between 2 groups of VLBW premature infants fed either exclusively formula (n = 40) or at least 50% breast milk (n = 40) during their hospitalization.

METHODS

A retrospective chart review was used to collect information concerning patient demographics, discharge information, and nutritional variables. Information regarding hospital costs was obtained from the hospital's patient accounting office.

MAIN OUTCOME MEASURES

Independent t tests were used to compare demographic data, length of hospitalization, and cost of care between the 2 groups.

PRINCIPAL RESULTS

No statistically significant differences in length of stay or cost of care were found between infants fed at least 50% breast milk and those who were exclusively formula fed. Descriptive data concerning length of stay and cost of care for VLBW infants and those infants weighing less than 1000 g are presented.

CONCLUSION

This article presents a descriptive comparative study on the effect of providing at least 50% breast milk feedings compared with formula feeding on days to discharge and cost of hospitalization in VLBW infants in the NICU. It also provides information concerning cost of care and length of stay in VLBW and infants weighing less than 1000 g.

Longitudinal study on trace mineral compositions (selenium, zinc, copper, manganese) in Korean human preterm milk

We measured selenium, zinc, copper and manganese concentrations in the human milk of Korean mothers who gave birth to preterm infants, and compared these measurements with the recommended daily intakes. The samples of human milk were collected postpartum at week-1, -2, -4, -6, -8, and -12, from 67 mothers who gave birth to preterm infants (< 34 weeks, or birth weight < 1.8 kg). All samples were analyzed using atomic absorption spectrophotometry. The concentrations of selenium were 11.8 ± 0.5, 11.4 ± 0.8, 12.7 ± 0.9, 11.4 ± 0.8, 10.8 ± 0.9, and 10.5 ± 1.3 µg/L, zinc were 7.8 ± 0.5, 9.1 ± 0.8, 7.2 ± 0.9, 8.0 ± 0.8, 7.4 ± 0.9, and 6.6 ± 1.2 mg/L, copper were 506 ± 23.6, 489 ± 29.4, 384 ± 33.6, 356 ± 32.9, 303 ± 35.0, and 301 ± 48.0 µg/L and manganese were 133 ± 4.0, 127 ± 6.0, 125 ± 6.0, 123 ± 6.0, 127 ± 6.0, and 108 ± 9.0 µg/L at week-1, -2, -4, -6, -8, and -12, respectively. The concentrations of selenium and zinc meet the daily requirements but that of copper is low and of manganese exceeds daily requirements recommended by the American Academy of Pediatrics, Committee on Nutrition.

Enteral feeding practices in the NICU: results from a 2009 Neonatal Enteral Feeding Survey

PURPOSE

: The purpose of this study was to examine the current management of the enteral feeding regimens of premature infants cared for in the neonatal intensive care unit (NICU).

SUBJECTS

: The study included responses from 70 neonatal nurses who participated in a 2009 Neonatal Enteral Feeding Survey distributed electronically to the National Association of Neonatal Nurses membership. These respondents were representative of both the United States and Canada, with 29 US states represented. The majority of respondents (95.7%) reported current nursing employment in a level III NICU.

DESIGN

: Survey research was used in this exploratory study. The survey, Enteral Tube Feeding Practices in the Neonatal Intensive Care Unit, was developed in collaboration with expert neonatal nurses and nutritionists, pilot tested, and distributed via electronic means.

METHODS

: Survey research was conducted according to the Dillman methodology. Data analysis included descriptive statistics and univariate analysis of variance assessing for significant differences in specific neonatal feeding practices reported. Thematic analysis was used to analyze the qualitative data reported.

OUTCOME MEASURES

: The outcome measures included the survey responses to the questions asked about the implementation of an enteral feeding protocol and various aspects of enteral feeding practices in the NICU.

RESULTS

: The majority of participants (60.9%) reported that an enteral feeding protocol was implemented in practice, but that it was inconsistently followed because of individual physician or nurse practice patterns, or highly individualized feeding plans required of specific clinical care needs of the patient. Respondents indicated that gestational age was the leading criteria used to initiate feedings, and patent ductus arteriosis treatment was the primary contraindication to enteral feedings. The leading factor reported to delay or alter enteral feedings was the presence of gastric residuals. Survey data indicated that other contraindicating factors to enteral feeding are variable across NICUs and, as reported, are often inconsistent with the current research published to date.

CONCLUSIONS

: Research is needed to provide a foundation on which to develop effective enteral feeding protocols that are appropriate for the diversity of infants cared for in the NICU. Such research findings will culminate in the development and implementation of enteral feeding protocols in the NICU, which will result in improved nutrition, growth, and development outcomes for premature infants.

Banked preterm versus banked term human milk to promote growth and development in very low birth weight infants

BACKGROUND

Human milk banking has been available in many countries for the last three decades. The milk provided from milk banking is predominantly term breast milk, but some milk banks provide preterm breast milk. There are a number of differences between donor term and donor preterm human milk.

OBJECTIVES

To determine the effect of banked preterm milk compared with banked term milk regarding growth and developmental outcome in very low birth weight infants (infants weighing less than 1500 g).

SEARCH STRATEGY

We used the standard methods of the Cochrane Neonatal Review Group, including a search of the Cochrane Neonatal Group specialized register and the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, January 2010). We searched the computerised bibliographic databases MEDLINE (1966 to February 2010), EMBASE (1988 to February 2010) and Web of Science (1975 to February 2010). We searched reference lists of all selected articles, review articles and the Oxford Database of Perinatal Trials. We also searched abstracts from neonatal and pediatric meetings (PAS electronic version from 2000 to 2009, ESPR hand search from 2000 to 2009). We applied no language restrictions.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing banked donor preterm milk with banked donor term milk regarding growth and developmental outcomes in very low birth weight infants

DATA COLLECTION AND ANALYSIS

We planned to perform assessment of methodology regarding blinding of randomisation, intervention and outcome measurements as well as completeness of follow-up. We planned to evaluate treatment effect using a fixed-effect model using relative risk (RR), relative risk reduction, risk difference (RD) and number needed to treat (NNT) for categorical data and using mean, standard deviation and weighted mean difference (WMD) for continuous data. We planned an evaluation of heterogeneity.

MAIN RESULTS

No studies met the inclusion criteria.

AUTHORS' CONCLUSIONS

There are no randomised trials that compare preterm banked milk to banked term milk to promote growth and development in very low birth weight infants.

Continuous feedings of fortified human milk lead to nutrient losses of fat, calcium and phosphorous

Substantial losses of nutrients may occur during tube (gavage) feeding of fortified human milk. Our objective was to compare the losses of key macronutrients and minerals based on method of fortification and gavage feeding method. We used clinically available gavage feeding systems and measured pre- and post-feeding (end-point) nutrient content of calcium (Ca), phosphorus (Phos), protein, and fat. Comparisons were made between continuous, gravity bolus, and 30-minute infusion pump feeding systems, as well as human milk fortified with donor human milk-based and bovine milk-based human milk fortifier using an in vitro model. Feeding method was significantly associated with fat and Ca losses, with increased losses in continuous feeds. Fat losses in continuous feeds were substantial, with 40 ± 3 % of initial fat lost during the feeding process. After correction for feeding method, human milk fortified with donor milk-based fortifier was associated with significantly less loss of Ca (8 ± 4% vs. 28 ± 4%, p< 0.001), Phos (3 ± 4% vs. 24 ± 4%, p < 0.001), and fat (17 ± 2% vs. 25 ± 2%, p = 0.001) than human milk fortified with a bovine milk-based fortifier (Mean ± SEM).

Clinical management of motility disorders in children

We review the current clinical evaluation and management of the most common esophageal and gastrointestinal motility disorders in children based on the literature and our experience in a pediatric motility center in the United States. The disorders discussed include esophageal achalasia, pre- and post-fundoplication motility disorders, gastroparesis, motility disorders occurring after repair of congenital atresias, motility disorders associated with gastroschisis, chronic intestinal pseudo-obstruction, motility after intestinal transplantation, motility disorders after colonic resection for Hirschsprung's disease, chronic functional constipation, and motility disorders associated with imperforate anus.

Diabetes and antenatal milk expressing: a pilot project to inform the development of a randomised controlled trial

OBJECTIVE

infants of women with diabetes in pregnancy are at increased risk of hypoglycaemia. If the infant's blood glucose is low and the mother is unable to breast feed/provide sufficient expressed breast milk, infants are often given formula. Some hospitals encourage women with diabetes to express breast milk before birth. However, there is limited evidence for this practice, including its impact on labour and birth, e.g. causing premature birth may be a concern. A pilot study was undertaken to establish the feasibility of conducting an adequately powered randomised controlled trial to evaluate this practice.

DESIGN

consecutive eligible women with pre-existing or gestational diabetes (requiring insulin), planning to breast feed and attending the study hospital were offered participation.

INCLUSION CRITERIA

34-36 weeks of gestation; singleton pregnancy; cephalic presentation; and able to speak, read and write in English.

EXCLUSION CRITERIA

history of spontaneous preterm birth, antepartum haemorrhage, placenta praevia and suspected fetal compromise. Women were encouraged to express colostrum twice a day from 36 weeks of gestation, and advised how to store the colostrum, which was frozen for their infant's use after birth. They were asked to keep a diary documenting their expressing.

DATA

demographic questionnaire, telephone interview at six and 12 weeks postpartum and medical record data.

SETTING

a public, tertiary, women's hospital in Melbourne, Australia.

PARTICIPANTS

43 women with diabetes in pregnancy (requiring insulin).

FINDINGS

cardiotocographs were undertaken after the first expressing episode and none of the infants showed any sign of fetal compromise. Forty per cent of infants received formula in the 24 hours postpartum. The proportion of infants receiving any breast milk at six weeks was 90%, and this decreased to 75% at 12 weeks. No women showed evidence of hypoglycaemia post expressing. The intervention was positively received by most women; 95% said that they would express antenatally again if the practice proved to be beneficial. The amount of colostrum varied according to the number of expressions, the length of time in the study and the time spent expressing, with a median of 14 days expressing and 39.6 ml of colostrum obtained.

KEY CONCLUSIONS

the small number of women in this pilot was not an adequate number to examine safety or efficacy, but this study does provide evidence that it would be feasible and desirable to conduct a randomised controlled trial of antenatal milk expressing for women with diabetes requiring insulin in pregnancy.

IMPLICATIONS FOR PRACTICE

it is important that this widespread practice undergoes rigorous evaluation to assess both efficacy and safety. Until such evidence is available, the authors suggest that the routine encouragement of antenatal milk expressing in women with diabetes in pregnancy should cease.