Use of human milk and fortification in the NICU.

Human milk is the gold standard to provide nutritional support for all healthy and sick newborn infants including the very low birth weight (VLBW) infant (<1500 g). It has both nutritional and anti-infective properties which are especially important for these infants at risk for sepsis and necrotizing enterocolitis. Human milk alone is insufficient to meet the nutritional needs for VLBW infants, especially protein and minerals. There is a conundrum between achieving the nutritional, immunologic, developmental, psychological, social, and economic benefit with human milk vs. the inadequate growth with unfortified human milk for VLBW leading to nutritional inadequacy, growth failure and poor neurodevelopmental outcome. The use of multicomponent fortifiers to increase calories and provide additional protein, vitamins, and minerals has been associated with short-term benefits in growth. Most current fortifiers are derived from cow's milk, however there are concerns regarding a possible association between the use of cow's milk-based fortifier and NEC. There is also an exclusive human milk diet with a fortifier derived solely from human milk. There are three approaches for fortifying human milk and include fixed dosage or "blind fortification", adjustable fortification using the blood urea nitrogen as a surrogate for protein nutriture to modify dosage of fortification, and targeted, individualized fortification that is based on periodic human milk analysis.

Low blood sugar levels in the newborn infant: Do changing goal posts matter?

Glucose supply and metabolism are essential for growth and normal brain development in both the fetus and newborn. Disorders of glucose availability and metabolism can result in either hypoglycemia or hyperglycemia. The first section of this manuscript will contrast recommendations from the American Academy of Pediatrics and the Pediatric Endocrine Society on the approach to defining neonatal hypoglycemia. Recent studies will be reviewed which add to the controversy. This review aims to discuss the evidence-based guidelines, definitions, pathogenesis, outcomes and management options in this field. The current variations in practices and possibilities of future trials are also addressed.

Fortification of human milk for preterm infants.

Human milk is the preferred feeding for all infants, including those of very low birth weight (<1500 g). It has both nutritional and anti-infective properties which are especially important for infants at risk for sepsis and necrotizing enterocolitis. When maternal milk is not available or the amount produced is not sufficient to meet daily needs, donor human milk may (should) be used in its place. However, donor human milk is generally term in quality and likely has insufficient protein to promote appropriate growth. Whether donor or mother's own milk, fortification of human milk is required to meet nutrient requirements for growth and development for these preterm infants who are at high risk for growth faltering during the hospital stay. There are multiple strategies and products that may be employed to support desired growth rates. The advent of human milk analyzers may be helpful in a more customized approach to fortification.

Neonatal hypoglycemia.

A consistent definition for neonatal hypoglycemia in the first 48 h of life continues to elude us. Enhanced understanding of metabolic disturbances and genetic disorders that underlie alterations in postnatal glucose homeostasis has added useful information to understanding transitional hypoglycemia. This growth in knowledge still has not led to what we need to know: "How low is too low and for how long?" This article reviews the current state of understanding of neonatal hypoglycemia and how different approaches reach different "expert" opinions.

Randomized Controlled Trial of Talactoferrin Oral Solution in Preterm Infants.

OBJECTIVE: To evaluate the safety and explore the efficacy of recombinant human lactoferrin (talactoferrin [TLf]) to reduce infection. STUDY DESIGN: We conducted a randomized, double blind, placebo-controlled trial in infants with birth weight of 750-1500 g. Infants received enteral TLf (n = 60) or placebo (n = 60) on days 1 through 28 of life; the TLf dose was 150 mg/kg every 12 hours. Primary outcomes were bacteremia, pneumonia, urinary tract infection, meningitis, and necrotizing enterocolitis (NEC). Secondary outcomes were sepsis syndrome and suspected NEC. We recorded clinical, laboratory, and radiologic findings, along with diseases and adverse events, in a database used for statistical analyses. RESULTS: Demographic data were similar in the 2 groups of infants. We attributed no enteral or organ-specific adverse events to TLf. There were 2 deaths in the TLf group (1 each due to posterior fossa hemorrhage and postdischarge sudden infant death), and 1 death in the placebo group, due to NEC. The rate of hospital-acquired infections was 50% lower in the TLf group compared with the placebo group (P < .04), including fewer blood or line infections, urinary tract infections, and pneumonia. Fourteen infants in the TLf group weighing <1 kg at birth had no gram-negative infections, compared with only 3 of 14 such infants in the placebo group. Noninfectious outcomes were not statistically significantly different between the 2 groups, and there were no between-group differences in growth or neurodevelopment over a 1-year posthospitalization period. CONCLUSION: We found no clinical or laboratory toxicity and a trend toward less infectious morbidity in the infants treated with TLf. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00854633.

Neonatal hypoglycemia.

PURPOSE OF REVIEW: The screening and management for neonatal hypoglycemia remains a confusing and contentious problem in neonatology. The purpose of this article is to contrast recent recommendations from the American Academy of Pediatrics and the Pediatric Endocrine Society. RECENT FINDINGS: Using different methodologies, the organizations have significant differences on whom to screen and what levels of glucose should be used for management. The identification of the first 48 h as a transitional hyperinsulinemic state is a new important concept. The neuroendocrine approach is contrasted with a neurodevelopmental strategy to find levels that exceed those associated with neuroglycopenia. SUMMARY: The questions remain the same when it comes to screening and management of neonatal low-glucose levels. Recent outcome studies with differing results continue to add to the controversy as to what to do at the bedside. It is uncertain if universal screening of glucose levels in the first hours should be applied to all newborn infants. Persistent hypoglycemic syndromes must be identified prior to discharge.

Metabolic screening and postnatal glucose homeostasis in the newborn.

Although individual metabolic diseases are relatively uncommon, inherited metabolic diseases collectively represent a more common cause of disease in the neonatal period than is generally appreciated. Newborn screening is among the most successful public health programs today. Every day, newborns considered to be at risk for hypoglycemia are screened. The definition of clinically significant hypoglycemia remains among the most confused and contentious issues in neonatology. There are 2 "competing" methods of defining hypoglycemia that suggest very different levels for management: one based on metabolic-endocrinologic hormones and another that uses outcome data to determine threshold levels of risk.

Fortification of human milk in very low birth weight infants (VLBW <1500 g birth weight).

The American Academy of Pediatrics supports the feeding of human milk for all infants. Very-low-birth-weight and extremely low-birth-weight infants especially can benefit from the immune and neurodevelopmental effects of human milk. However, human milk alone is nutritionally inadequate for the rapid growth of the very-low-birth-weight infant during a critical window for brain development and requires fortification to meet current recommendations. There are a variety of products, devices, and strategies that can be used to fine tune nutritional support of these very vulnerable infants.

Creamatocrit analysis of human milk overestimates fat and energy content when compared to a human milk analyzer using mid-infrared spectroscopy.

BACKGROUND AND OBJECTIVE: Human milk (HM) is the preferred feeding for human infants but may be inadequate to support the rapid growth of the very-low-birth-weight infant. The creamatocrit (CMCT) has been widely used to guide health care professionals as they analyze HM fortification; however, the CMCT method is based on an equation using assumptions for protein and carbohydrate with fat as the only measured variable. The aim of the present study was to test the hypothesis that a human milk analyzer (HMA) would provide more accurate data for fat and energy content than analysis by CMCT. METHODS: Fifty-one well-mixed samples of previously frozen expressed HM were obtained after thawing. Previously assayed "control" milk samples were thawed and also run with unknowns. All milk samples were prewarmed at 40°C and then analyzed by both CMCT and HMA. CMCT fat results were substituted in the CMCT equation to reach a value for energy (kcal/oz). Fat results from HMA were entered into a computer model to reach a value for energy (kcal/oz). Fat and energy results were compared by paired t test with statistical significance set at P < 0.05. An additional 10 samples were analyzed locally by both methods and then sent to a certified laboratory for quantitative analysis. Results for fat and energy were analyzed by 1-way analysis of variance with statistical significance set at P < 0.05. RESULTS: Mean fat content by CMCT (5.8 ± 1.9 g/dL) was significantly higher than by HMA (3.2 ± 1.1 g/dL, P < 0.001). Mean energy by CMCT (21.8 ± 3.4 kcal/oz) was also significantly higher than by HMA (17.1 ± 2.9, P < 0.001). Comparison of biochemical analysis with HMA of the subset of milk samples showed no statistical difference for fat and energy, whereas CMCT was significantly higher than for both fat (P < 0.001) and energy (P = 0.002). CONCLUSIONS: The CMCT method appears to overestimate fat and energy content of HM samples when compared with HMA and biochemical methods.

Postnatal glucose homeostasis in late-preterm and term infants.

This report provides a practical guide and algorithm for the screening and subsequent management of neonatal hypoglycemia. Current evidence does not support a specific concentration of glucose that can discriminate normal from abnormal or can potentially result in acute or chronic irreversible neurologic damage. Early identification of the at-risk infant and institution of prophylactic measures to prevent neonatal hypoglycemia are recommended as a pragmatic approach despite the absence of a consistent definition of hypoglycemia in the literature.

Feeding problems in the late preterm infant.

Much of the neonatal nutrition literature has focused on the management of very low birth weight infants, a group of infants usually less than 33 weeks gestation. Much less attention has been paid to nutritional management issues in preterm infants at higher gestations. This article reviews nutritional issues that exist from the 239th day (34 0/7 weeks gestation) and ending on the 259th day (36 6/7 weeks gestation) since the first day of the mother's last normal menstrual period.

Pragmatic approach to in-hospital nutrition in high-risk neonates.

Extremely low birth weight infants may experience periods of moderate to severe undernutrition during the acute phase of their respiratory problems. This undernutrition contributes to early growth deficits in these patients and may have long-lasting effects, including poor neurodevelopmental outcome. Early postnatal intravenous amino-acid administration and early enteral feeding strategies will minimize the interruption of nutrient intake that occurs with premature birth. These two strategies will prevent intracellular energy failure, allow the administration of more non-protein energy, as well as enhance overall nutritional health, as evidenced by less postnatal weight loss and earlier return to birth weight, and improved overall postnatal growth and outcome.