Bibian van der Voorn

Antenatal Glucocorticoid Treatment and Polymorphisms of the Glucocorticoid and Mineralocorticoid Receptors are Associated with IQ and Behavior in Young Adults Born Very Preterm

CONTEXT Preterm survivors exhibit neurodevelopmental impairments. Whether this association is influenced by antenatal glucocorticoid treatment and glucocorticoid sensitivity is unknown. OBJECTIVES This study aimed to study the effects of antenatal glucocorticoid treatment and glucocorticoid receptor (GR) and mineralocorticoid receptor (MR) polymorphisms on behavior and intelligence quotient (IQ). DESIGN This study was part of the 19-year follow-up of the Project On Preterm and Small-for-gestational-age birth cohort. SETTING Multicenter study. PATIENTS Three hundred forty-four 19-year-olds born very preterm (gestational age < 32 wk), of whom 71 had received betamethasone antenatally. INTERVENTION Single antenatal treatment course of betamethasone. MAIN OUTCOME MEASURES Behavior (Young Adult Self Report and Young Adult Behavior Checklist for parents) and IQ (digital Multicultural Capacity Test-intermediate level). Data were analyzed by linear regression and presented as regression coefficient (95% confidence interval [CI]). RESULTS Sex ratio, GR (R23K; N363S) and MR (-2G/C; I180V) genotypes were equally distributed between treated and nontreated subjects. Independent of treatment, R23K carriers had improved IQ scores (β 9.3; 95% CI, 3.4 to 15.1) and a tendency toward more favorable total problem behavior scores (β -8.5; 95% CI, -17.3 to 0.2) ; -2G/C CC carriers had poorer IQ scores (β -6.2; 95% CI, -10.5 to -1.9); I180V carriers had more favorable internalizing behavior scores (β -2.0; 95% CI, -3.9 to -0.1). Antenatal glucocorticoid treatment was associated with more unfavorable behavior scores, especially internalizing behavior (β 2.4; 95% CI, 0.3 to 4.5). Interaction between GR and MR polymorphisms and antenatal glucocorticoid treatment was observed, with poorer IQ scores for exposed N363S carriers; poorer intellectual subdomain scores for exposed I180V-carriers; more favorable total problem behavior scores for exposed R23K carriers. CONCLUSIONS Genetic variations in glucocorticoid sensitivity and antenatal glucocorticoid treatment are associated with IQ and behavior in young adult preterm survivors.

Management and outcome of 35 cases with foetal/neonatal alloimmune neutropenia

The aim of this study was to provide an overview of foetal/neonatal alloimmune neutropenia (FNAIN), together with advice on the clinical management.

Determination of cortisol and cortisone in human mother's milk

Humanmothers milk is recommended as the standard nutrition for neonates, due to its widely acknowledged benefits. Besides being a source of nutrients, milk contains a variety of non-nutritive bioactive and immunomodulatory components [1]. Glucocorticoids are found in mothers milk, bound mainly to corticosteroid binding globulin and albumin [2]. Glucocorticoids are suggested to induce proliferation and differentiation of glandular cells in the mammary gland, and also to influence the neonate via the mothers milk [2,3]. Despite efforts to optimize the contents of formula feeding, humanmilk is still recommended for its widely acknowledged benefits. Maternal glucocorticoids might be one of the factors contributing to the advantages of breast milk over formula feeding and are therefore worthwhile to investigate. In order to be able tomeasure glucocorticoids in humanmilk we developed a reliable liquid chromatography–tandem mass spectrometry (LC–MS/MS) method to determine cortisol and cortisone in mothers milk. In this letter, we describe thismethod and the results of the validation of our assay, including experiments that investigated the stability of cortisol and cortisone in human milk. Donor mothers milk from 13 healthy mothers who donated between 8 to 28 weeks postpartum to the Dutch Human Milk Bank of the VU University Medical Center, Amsterdam was used. All samples were stored in polypropylene vials at −20 °C. Preparation of the sampleswas initiated by the addition of H4 labeled cortisol (Cambridge Isotope Laboratories) and H8 labeled cortisone (CDN Isotopes Inc.), both serving as internal standards, to 200 μL thawed milk and thorough mixing. To remove undesired lipids, the milk was washed by the addition of 2 mL hexane [2]. Capped tubes were mixed for 2 min in a multivortexer and centrifuged for 2 min, at 19 °C, 1900 g, resulting in the separation of the lipid layer from the aqueous layer. Thereafter the sample was frozen in a −60 °C CO2 ice bath, which enabled the liquid hexane to be decanted from the frozen milk. This washing procedure was completed three times, in total. Forty μL of the washed milk was injected onto a Symbiosis online solid phase extraction (SPE) system (Spark Holland, Emmen, The Netherlands). Online SPE with C8 cartridges (Spark Holland) was performed for further purification of the samples. The analyte was eluted from the cartridge with methanol–water and focused on the Synergi Hydro RP column (Phenomenex, Utrecht, The Netherlands), which was equipped with a C18 guard column (Phenomenex). A linear binary

Glucocorticoid Programming in Very Preterm Birth

Very preterm (i.e., <32 weeks of gestation) infants admitted to the neonatal intensive care unit are compromised in their abilities to respond adequately to common threats like hemodynamic changes and reduced energy supplies, which is partly attributable to adrenocortical insufficiency. Conversely, later in life, these infants show features of increased glucocorticoid bioactivity, such as abdominal fat distribution, raised blood pressure, insulin resistance and diabetes mellitus type 2. It has been suggested that the very preterm newborn responds to the adverse postnatal environment with a sustained elevation in hypothalamus-pituitary-adrenal axis activity that persists beyond infancy. This has implications for subsequent growth, body composition, metabolism, neurodevelopment and, ultimately, long-term disease risk. The mechanisms underpinning these associations are not fully elucidated yet. This review gives a brief summary of studies that investigated adrenocortical function in very preterm newborns and how the axis changes with age, as a possible explanation for the association between prematurity and long-term outcome.

Cortisol in human milk: The good, the bad, or the ugly?

We found that breast-milk cortisol and cortisone concentrations peaked at 0700 h and declined during the afternoon, mirroring saliva analysis that was conducted at the same time (3). The early-morning peak was approximately five times as high as the nadir. Moreover, cortisone (which can be converted to cortisol by 11b-reductase activity) was much more abundant in breast milk than cortisol (3). Recently, another group demonstrated replication of this typical diurnal pattern in human milk (4).

Programming of the Hypothalamus-Pituitary-Adrenal Axis by Very Preterm Birth

Background: Many very preterm (i.e., <32 weeks of gestation) newborns fail to mount an adequate adrenocortical response to stress or illness, termed relative adrenal insufficiency. Conversely, later in life these infants show features of increased glucocorticoid bioactivity, such as abdominal adiposity, insulin resistance, raised blood pressure, shorter stature and internalizing problem behavior. Summary: Studies suggested that very preterm newborns have impairments along multiple levels of the hypothalamus-pituitary-adrenal (HPA) axis. Among the impairment were defects in: (1) the pituitary responsiveness to exogenous corticotropin-releasing hormone, (2) 11β-hydroxylase activity, and (3) the interconversion between cortisol and inert cortisone. There is some evidence suggesting that later in life these infants have an increased basal secretion rate of cortisol and adrenal hyperandrogenism. However, the response to acute (psychosocial) stress was blunted rather than enhanced in them. The mechanisms explaining this switch in HPA axis activity are complex and not yet fully understood. Key Messages: Very preterm newborns have several impairments along the HPA axis that could impede an adequate adrenocortical response to stress or illness. Later in life, these infants are predisposed to increased HPA axis activity, which could partially explain their phenotype.

Birth weight and postnatal growth in preterm born children are associated with cortisol in early infancy, but not at age 8 years.

BACKGROUND Preterm birth has been associated with altered hypothalamic-pituitary-adrenal (HPA-) axis activity as well as cardiometabolic diseases and neurodevelopmental impairments later in life. We assessed cortisol from term age to age 8 y in children born preterm, to explore the development of HPA-axis activity in association with intrauterine and early-postnatal growth until 6 mo. corrected age. METHODS In 152 children born at a gestational age ≤32 wks. and/or with a birth weight ≤1,500g, random serum cortisol was assessed at term age (n=150), 3 mo. (n=145) and 6 mo. corrected age (n=144), and age 8 y (n=59). Salivary cortisol was assessed at age 8 y (n=75): prior to bedtime, at awakening, 15min after awakening, and before lunch. Cortisol was analyzed in association with birth weight-standard deviation score (SDS), being born small for gestational age (SGA), and combinations of intrauterine and postnatal growth: appropriate for gestational age (AGA) with or without growth restriction (AGA GR+ or AGA GR-) at 6 mo. corrected age, and SGA with or without catch-up growth (SGA CUG+ or SGA CUG-) at 6 mo. corrected age. Cross-sectional associations at all time points were analyzed using linear regression, and longitudinal associations were analyzed using generalized estimating equations. RESULTS Longitudinally, birth weight-SDS was associated with cortisol (β [95%CI]): lower cortisol over time was seen in infants with a birth weight ≤-2 SDS (-50.69 [-94.27; -7.11], p=0.02), infants born SGA (-29.70 [-60.58; 1.19], p=0.06), AGA GR+ infants (-55.10 [-106.02; -4.17], p=0.03) and SGA CUG- infants (-61.91 [-104.73; -19.10], p=0.01). In cross-sectional analyses at age 8 y, no associations were found between either serum or salivary cortisol and birth weight-SDS, SGA-status, or growth from birth to 6 mo. corrected age. CONCLUSION In children born preterm, poor intrauterine and postnatal growth were associated with lower cortisol in early infancy, but not at age 8 y. Even though HPA-axis activity no longer differed between groups at age 8 y, or differences could not be confirmed due to attrition, it is unknown whether the differences found in early infancy could attribute to increased health risks later in life.

Stability of Cortisol and Cortisone in Human Breast Milk During Holder Pasteurization

ABSTRACT Human donor milk is the feeding of choice for preterm infants, when own mothers milk is not available. Holder pasteurization is necessary to secure the safety of donor milk, although it can affect milk quality by reduction of nutritional and bioactive components. Recently, research has focused on the potential role of breast milk glucocorticoids for infant development. At this moment, it is unknown whether pasteurization affects milk glucocorticoid levels. Therefore, we assessed whether Holder pasteurization, the most frequently used method nowadays, reduces breast milk cortisol and cortisone levels, using breast milk samples from 30 women who delivered at term. We found tight correlations between pre- and postpasteurization levels of cortisol (R2 = 0.99) and cortisone (R2 = 0.98), and good agreement in Passing and Bablok regression analysis. In conclusion, cortisol and cortisone in human term breast milk are not significantly affected by Holder pasteurization.

Nutritional programming by glucocorticoids in breast milk: Targets, mechanisms and possible implications

Vertical transmission of glucocorticoids via breast milk might pose a mechanism through which lactating women could prepare their infants for the postnatal environment. The primary source of breast-milk glucocorticoids is probably the systemic circulation. Research from our group showed that milk cortisol and cortisone concentrations follow the diurnal rhythm of maternal hypothalamus-pituitary-adrenal axis activity, with a higher abundance of cortisone compared to cortisol. Measurement of breast-milk glucocorticoid concentrations is challenging due to possible cross-reactivity with progestagens and sex steroids, which are severely elevated during pregnancy and after parturition. This requires precise methods that are not hindered by cross reactivity, such as LC-MS/MS. There are some data suggesting that breast-milk glucocorticoids could promote intestinal maturation, either locally or after absorption into the systemic circulation. Breast-milk glucocorticoids might also have an effect on the intestinal microbiome, although this has not been studied thus far. Findings from studies investigating the systemic effects of breast-milk glucocorticoids are difficult to interpret, since none took the diurnal rhythm of glucocorticoids in breast milk into consideration, and various analytical methods were used. Nevertheless, glucocorticoids in breast milk might offer a novel potential pathway for signal transmission from mothers to their infants.