Bernard L Salle

Enteral nutrient supply for preterm infants: commentary from the European Society of Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition.

The number of surviving children born prematurely has increased substantially during the last 2 decades. The major goal of enteral nutrient supply to these infants is to achieve growth similar to foetal growth coupled with satisfactory functional development. The accumulation of knowledge since the previous guideline on nutrition of preterm infants from the Committee on Nutrition of the European Society of Paediatric Gastroenterology and Nutrition in 1987 has made a new guideline necessary. Thus, an ad hoc expert panel was convened by the Committee on Nutrition of the European Society of Paediatric Gastroenterology, Hepatology, and Nutrition in 2007 to make appropriate recommendations. The present guideline, of which the major recommendations are summarised here (for the full report, see http://links.lww.com/A1480), is consistent with, but not identical to, recent guidelines from the Life Sciences Research Office of the American Society for Nutritional Sciences published in 2002 and recommendations from the handbook Nutrition of the Preterm Infant. Scientific Basis and Practical Guidelines, 2nd ed, edited by Tsang et al, and published in 2005. The preferred food for premature infants is fortified human milk from the infants own mother, or, alternatively, formula designed for premature infants. This guideline aims to provide proposed advisable ranges for nutrient intakes for stable-growing preterm infants up to a weight of approximately 1800 g, because most data are available for these infants. These recommendations are based on a considered review of available scientific reports on the subject, and on expert consensus for which the available scientific data are considered inadequate.

Perinatal metabolism of vitamin D

During pregnancy, maternal serum concentrations of 25-hydroxyvitamin D, the circulating form of vitamin D, correlate with dietary vitamin D intake. Maternal serum concentrations of 1,25-dihydroxyvitamin D, the hormonal circulating and active form of vitamin D, are elevated during pregnancy; 1,25-dihydroxyvitamin D is synthesized mainly by the decidual cells of the placenta and allows for increased calcium absorption. The fetus is entirely dependent on the mother for its supply of 25-hydroxyvitamin D, which is believed to cross the placenta. Hypocalcemia and increased parathyroid hormone secretion induce synthesis of 1,25-dihydroxyvitamin D after birth in both full-term and preterm neonates. Nevertheless, serum concentrations of 25-hydroxyvitamin D are a rate-limiting factor in the synthesis of 1,25-dihydroxyvitamin D. In vitamin D-replete infants, circulating 1,25-dihydroxyvitamin D concentrations are higher than those observed in older infants. In countries where dairy products are not routinely supplemented with vitamin D, maternal vitamin D supplementation during pregnancy is necessary. However, there is no indication for the use of pharmacologic doses of vitamin D or its metabolites in the perinatal period.

Body composition in appropriate and in small for gestational age infants

The body composition of 70 appropriate for gestational age newborn infants whose gestational age ranged from 32 to 41 weeks was determined by dual‐energy X‐ray absorptiometry during the first 48 h of life. The evolution of the bone mineral content, fat and lean mass was well correlated with gestational age (r= 0.66, r= 0.66 and r= 0.82. respectively) but even more closely with birthweight (r= 0.85, r= 0.91 and r= 0.97. respectively). The body composition of 20 symmetric small for gestational age infants (mean gestational age ± SD = 38.1 ± 1.2 weeks: mean birthweight ± SD = 2117 ± 183 g) was also studied. The total body fat, the lean mass and the bone mineral content of small for gestational age infants were decreased significantly in comparison with those of appropriate for gestational age infants with the same gestational age (p≤ 0.05, p≤ 0.0001 and p≤ 0.05) but was not significantly different from those observed in appropriate for gestational age infants of the same birthweight.

Vitamin D supplementation during pregnancy: Effect on neonatal calcium homeostasis

We assessed whether modification of vitamin D nutritional status during the last trimester of pregnancy affects maternal and neonatal calcium homeostasis. At the end of the first trimester, 40 pregnant women were randomly assigned to either of two groups, and blood taken to assess the basal values of Ca, Pi, Mg, iPTH, 25-OHD, and 1,25(OH)2D. From the sixth month on, group 1 (+D) received 1000 IU vitamin D3 daily; group 2 (-D) served as control. At the time of delivery, maternal serum 25-OHD was higher in the +D group (P less than 0.0005). Ca, Pi, iPTH, and 1,25(OH)2D were not affected. At term, venous cord 25-OHD levels were also higher in the +D group (P less than 0.0005), and 1,25(OH)2D levels slightly lower (P less than 0.05), but neither Ca, Pi, nor iPTH differed between the two groups. Serum CaT dropped significantly (P less than 0.002) at 4 days of age in the infants from both groups, although to a lesser extent in these from the +D group (P less than 0.05). Circulating iPTH increased in both groups. Serum 25-OHD remained low in the -D group, and dropped slightly in the +D group; 1,25(OH)2D remained stable during the first 4 days of life in the -D group, and increased in the +D group (P less than 0.001). Our data demonstrate the importance of providing adequate maternal vitamin D stores to ensure better perinatal handling of calcium. This is of particular importance for populations at risk for hypovitaminosis D.

Lumbar bone mineral content measured by dual energy X‐ray absorptiometry in newborns and infants

Dual energy X‐ray absorptiometry (DXA), a non‐invasive method for measuring small amounts of mineral, was used to assess the bone mineral content (BMC) and bone mineral density (BMD) of the lumbar spine (5 vertebrae) in 57 newborns (on day 1‐2) and 22 infants (1‐24 months of age). A modified high‐resolution program (Hologic) allowed us to assess BMC and BMD with a precision higher than 2.4% and 1.5%, respectively. In newborns, BMC and BMD correlated positively with birth weight, body area, length and gestational age:r= 0.73, 0.71, 0.63 and 0.60, respectively, for BMC; and r=0.59, 0.58, 0.54 and 0.53, respectively, for BMD. In infants, both BMC and BMD were highly correlated with weight, age, length and body area over two years (r= 0.94 or better in each instance). The data provide normal values for lumbar spine BMC and BMD in newborns (gestational age 31‐40) and infants up to two years of age; DXA appears to be an excellent and safe tool for pediatric bone mineral measurements.

Bone mineral metabolism in the micropremie.

Environmental factors, nutritional supplies, hormonal status, diseases, and treatments appear to affect postnatal skeletal growth and mineralization in VLBW infants. Compared with their term counterparts, ELBW infants are at risk of postnatal growth deficiency and osteopenia at the time of hospital discharge. From recent data, DXA is becoming one of the reference techniques to evaluate mineral status, whole-body composition, and effects of dietary manipulations on weight gain composition and mineral accretion in preterm infants. Weight gain and length increases need to be evaluated carefully during the first weeks of life, in the intensive care unit and out of it, in the step down unit. Nutritional survey is required to improve the nutritional supply and to maximize linear growth. As the critical epoch of growth extends, during the first weeks or months after discharge, follow-up and nutritional support need to be provided during the first years to promote early catch-up growth and mineralization. Further studies need to determine precisely the most optimal feeding regimen during this period but also need to evaluate the long-term implications of such a policy on stature, peak bone mass, and general health at adulthood.

Dual energy X-ray absorptiometry measurement of bone mineral content in newborns : validation of the technique

ABSTRACT: To evaluate the applicability of dual energy x-ray bone absorptiometry in newborns, precision and accuracy of the method was tested for very small quantities of mineral ranging from less than 0.5 g to about 4 g of hydroxyapatite using a Hologic QDR 1000 instrument. For six femurs excised from preterm stillborns, the mean precision for bone mineral content (BMC) and bone mineral density (BMD) was 1.2 and 0.8%, respectively. Accuracy based on ash weight indicated a mean overestimation of about 7%. In vivo, the precision was assessed by measuring lumbar spine BMC and BMD (L1 to L5) two or three times in 10 newborns (gestational age, 33 to 40 wk). The mean coefficients of variation were 2.40 and 1.55% for BMC and BMD, respectively. Lumbar spine BMC and BMD were also measured once in 30 full-term infants. Values ranged from 1.17 to 3.90 g for BMC and from 0.192 to 0.356 g/cm2 for BMD. The present study shows that dual energy x-ray absorptiometry provides a valuable new tool for the assessment and management of BMC in low birth weight infants and neonates in general.

Vitamin D metabolism in preterm infants: Serum calcitriol values during the first five days of life†

To ascertain the activity of the vitamin D biosynthetic pathway, the serum concentration of 1,25-dihydroxyvitamin D (calcitriol) was measured in 16 preterm infants (32 to 37 weeks of gestation) at 1 to 2 and 120 hours of age. Half of the subjects received a daily oral supplement of 2,100 IU of vitamin D3 during the five-day study period. In the first two hours of life, all subjects were hypocalcemic (8.2 +/- 0.2 mg/dl) and 14 subjects had low concentrations of 25-hydroxyvitamin D (calcidiol, 8 +/- 1 ng/ml). The latter finding probably reflects a mild degree of vitamin D deficiency in the mothers of our subjects. Calcitriol concentrations (42 +/- 3 pg/ml) were comparable to those of older children. At 120 hours of age, the control group had no significant change in calcitriol values, whereas the group supplemented with D3 had a more than threefold increase. There was a positive correlation between the circulating concentrations of calcidiol and calcitriol over the period of the study. The data show that, after 32 weeks of gestation, renal 25-hydroxyvitamin D-1 alpha-hydroxylase activity is present, with the rate of calcitriol synthesis being apparently substrate limited. Early neonatal hypocalcemia is therefore unlikely to be caused by an impairment of vitamin D activation.

Aetiology, morphology and body composition of infants born small for gestational age.

Infants born small for gestational age (SGA) are a heterogeneous group. Both the timing and duration of the intrauterine insult determine the physical condition and body composition of the infant at birth. Infants with symmetrical intrauterine growth retardation (IUGR) have a similar body composition at birth to weight‐matched infants born appropriate for gestational age. However, these infants are more likely to remain shorter and lighter than normal infants. In contrast, infants with asymmetrical IUGR have reduced fat deposition but are more likely to exhibit catch‐up growth during the first few months of life. The low mortality and morbidity rates in infants born SGA observed in recent studies are linked to their appropriate perinatal management, including adequate early nutritional support. □ Body composition, dual‐energy X‐ray absorptiometry, aetiology, neonate, preterm, small for gestational age

Supplementation of pooled human milk with casein hydrolysate: energy and nitrogen balance and weight gain composition in very low birth weight infants.

ABSTRACT.: Growth and nitrogen and energy balances were studied with a combined technique of nutrient balance and indirect calorimetry measurement in two groups of eight very low birth weight infants fed pooled pasteurized human milk (HM) or cows milk casein hydrolysate supplemented HM (HM-Pr). There was no difference in the amount of energy absorbed (91 ± 17 kcal/kg/day with HM-Pr versus 95 ± 8 with HM-P) or in the growth rate. The infants fed HM-Pr had a higher nitrogen intake (602 ± 80 versus 395 ± 64 mg/kg/day; p < 0.001), urinary nitrogen excretion (160 ± 64 versus 78 ± 16 mg/kg/day; p < 0.005) and nitrogen retention (326 ± 32 versus 252 ± 48 mg/kg/day; p < 0.01). They also had increased plasma concentrations of essential amino acids, urea nitrogen, and total protein without metabolic imbalance. Energy expenditure was higher (58 versus 49 kcal/kg/day; p < 0.005) and energy storage lower (33 versus 47 kcal/kg/day; p < 0.05) with HM-Pr. In percent of weight gain, protein and fat accretion represented 12 and 14% in HM-Pr group versus 10 and 27% in HM group. Very low birth weight infants fed casein hydrolysate supplemented pooled HM achieved a growth rate and a weight gain composition similar to the fetus.