Christina J. Valentine

A.S.P.E.N. Position Paper: Recommendations for Changes in Commercially Available Parenteral Multivitamin and Multi–Trace Element Products

The parenteral multivitamin preparations that are commercially available in the United States (U.S.) meet the requirements for most patients who receive parenteral nutrition (PN). However, a separate parenteral vitamin D preparation (cholecalciferol or ergocalciferol) should be made available for treatment of patients with vitamin D deficiency unresponsive to oral vitamin D supplementation. Carnitine is commercially available and should be routinely added to neonatal PN formulations. Choline should also be routinely added to adult and pediatric PN formulations; however, a commercially available parenteral product needs to be developed. The parenteral multi-trace element (TE) preparations that are commercially available in the U.S. require significant modifications. Single-entity trace element products can be used to meet individual patient needs when the multiple-element products are inappropriate (see Summary/A.S.P.E.N. Recommendations section for details of these proposed modifications).

A.S.P.E.N. Position Paper Clinical Role for Alternative Intravenous Fat Emulsions

The currently available, standard soybean oil (SO)-based intravenous fat emulsions (IVFEs) meet the needs of most parenteral nutrition (PN) patients. There are alternative oil-based fat emulsions, such as medium-chain triglycerides (MCTs), olive oils (OOs), and fish oils (FOs), that, based on extensive usage in Europe, have an equivalent safety profile to SO. These alternative IVFEs are metabolized via different pathways, which may lead to less proinflammatory effects and less immune suppression. These alternative oil-based IVFEs are not currently available in the United States. Many patients who require IVFEs are already in a compromised state. Such patients could potentially have better clinical outcomes when receiving one of the alternative IVFEs to diminish the intake of the potentially proinflammatory ω-6 fatty acid-linoleic acid-which comprises more than 50% of the fatty acid profile in SO. Further research is needed on these alternative oil-based IVFEs to identify which IVFE oils or which combination of oils may be most clinically useful for specific patient populations.

DHA supplementation: current implications in pregnancy and childhood.

Dietary supplementation with ω-3 long chain fatty acids including docosahexaenoic acid (DHA) has increased in popularity in recent years and adequate DHA supplementation during pregnancy and early childhood is of clinical importance. Some evidence has been built for the neuro-cognitive benefits of supplementation with long chain polyunsaturated fatty acids (LCPUFA) such as DHA during pregnancy; however, recent data indicate that the anti-inflammatory properties may be of at least equal significance. Adequate DHA availability in the fetus/infant optimizes brain and retinal maturation in part by influencing neurotransmitter pathways. The anti-inflammatory properties of LCPUFA are largely mediated through modulation of signaling either directly through binding to receptors or through changes in lipid raft formation and receptor presentation. Our goal is to review the current findings on DHA supplementation, specifically in pregnancy and infant neurodevelopment, as a pharmacologic agent with both preventative and therapeutic value. Given the overall benefits of DHA, maternal and infant supplementation may improve neurological outcomes especially in vulernable populations. However, optimal composition of the supplement and dosing and treatment strategies still need to be determined to lend support for routine supplementation.

Randomized Controlled Trial of Docosahexaenoic Acid Supplementation in Midwestern U.S. Human Milk Donors

BACKGROUND Docosahexaenoic acid (DHA) is a long-chain polyunsaturated fatty acid important for neonatal neurodevelopment and immune homeostasis. Preterm infants fed donor milk from a Midwestern source receive only 20% of the intrauterine accretion of DHA. We tested the hypothesis that DHA supplementation of donor mothers would provide preterm infants with DHA intake equivalent to fetal accretion. SUBJECTS AND METHODS After Institutional Review Board approval and informed consent, human milk donors to the Mothers Milk Bank of Ohio were randomized to receive 1 g of DHA (Martek(®) [now DSM Nutritional Lipids, Columbia, MD]) or placebo soy oil. Dietary intake data were collected and analyzed by a registered dietitian. Fatty acids were measured by gas chromatography/flame ionization detection. Statistical analysis used linear mixed models. RESULTS Twenty-one mothers were randomly assigned to either the DHA group (n=10) or the placebo group (n=11). Donor age was a median of 31 years in both groups with a mean lactational stage of 19 weeks. Dietary intake of DHA at baseline in both groups was a median of 23 mg/day (range, 0-194 mg), significantly (p<0.0001) less than the minimum recommended intake of 200 mg/day. The DHA content of milk increased in the DHA-supplemented group (p<0.05). CONCLUSIONS The women enrolled in this study had low dietary DHA intake. Supplementation with preformed DHA at 1 g/day resulted in increased DHA concentrations in the donor milk with no adverse outcomes. Infants fed donor milk from supplemented women receive dietary DHA levels that closely mimic normal intrauterine accretion during the third trimester.

Nutritional Management of the Breastfeeding Dyad

Milk is successfully produced by mothers regardless of their nutritional status. Nevertheless, the concentrations of some nutrients, specifically vitamins A, D, B1, B2, B3, B6, and B12, fatty acids, and iodine, in human milk depend on or are influenced by maternal diet. A healthy and varied diet during lactation ensures adequate maternal nutrition and optimal concentration of some nutrients in human milk. Exclusive breastfeeding meets the nutritional needs of infants for 6 months of life with the exception of vitamins D and K, which should be given to breastfed infants as supplements.

A Call to Action to Bring Safer Parenteral Micronutrient Products to the U.S. Market

The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) started an intensive review of commercially available parenteral vitamin and trace element (TE) products in 2009. The chief findings were that adult multi-TE products currently available in the United States (U.S.) provide potentially toxic amounts of manganese, copper, and chromium, and neonatal/pediatric multi-TE products provide potentially toxic amounts of manganese and chromium. The multivitamin products appeared safe and effective; however, a separate parenteral vitamin D product is needed for those patients on standard therapy who continue to be vitamin D depleted and are unresponsive to oral supplements. The review process also extended to parenteral choline and carnitine. Although choline and carnitine are not technically vitamins or trace elements, choline is an essential nutrient in all age groups, and carnitine is an essential nutrient in infants, according to the Food and Nutrition Board of the Institute of Medicine. A parenteral choline product needs to be developed and available. Efforts are currently under way to engage the U.S. Food and Drug Administration (FDA) and the parenteral nutrient industry so A.S.P.E.N.s recommendations can become a commercial reality.

Factors Associated with Breastfeeding Initiation in Adolescent Mothers

OBJECTIVE To identify the most influential factors on breastfeeding initiation in adolescent mothers in order to identify the highest risk population to focus education and support services. STUDY DESIGN Retrospective population-based cohort study of all non-anomalous live births in Ohio (2006-2007). Breastfeeding initiation rates were compared between adolescent mothers age ≤ 19 years and a reference group age >19 years. A multivariate logistic regression model assessed the association between breastfeeding initiation in adolescent mothers while adjusting for important concomitant risk factors including race, socioeconomic, demographic, prenatal, and delivery factors. RESULTS Of 308,380 births during the study period, following exclusions there were 30,402 mothers ≤ 19 years of age (10.5% of study population) and 257,840 mothers age >19 years. Of adolescent mothers, 44% initiated breastfeeding compared with 65% of older mothers, P < .001. Adolescents were 33% less likely to breastfeed after adjusting for important coexisting factors, adjusted relative risk 0.77 (95% CI 0.75-0.80). Socioeconomic factors had the most significant influence on breastfeeding initiation in adolescent mothers. CONCLUSION Adolescent mothers who have the least social support and are socioeconomically disadvantaged are the least likely to breastfeed their newborn infants. In addition, maternal perception, societal barriers, and a lack of prenatal intervention contribute unique barriers to breastfeeding in adolescence. Opportunities exist for school programs, baby-friendly hospitals, and postpartum education to improve breastfeeding rates in this population.

Neonatal Body Composition Measuring Lean Mass as a Tool to Guide Nutrition Management in the Neonate

Neonatal nutrition adequacy is often determined by infant weight gain. The aim of this review is to summarize what is currently known about neonatal body composition and the use of body composition as a measure for adequate neonatal nutrition. Unlike traditional anthropometric measures of height and weight, body composition measurements account for fat vs nonfat mass gains. This provides a more accurate picture of neonatal composition of weight gain. Providing adequate neonatal nutrition in the form of quantity and composition can be a challenge, especially when considering the delicate balance of providing adequate nutrition to preterm infants for catch-up growth. Monitoring weight gain as fat mass and nonfat mass while documenting dietary intake of fat, protein, and carbohydrate in formulas may help provide the medical community the tools to provide optimal nutrition for catch-up growth and for improved neurodevelopmental outcomes. Tracking body composition in term and preterm infants may also provide critical future information concerning the nutritional state of infants who go on to develop future disease such as obesity, hypertension, and hyperlipidemia as adolescents or adults.

Maternal Dietary DHA Supplementation to Improve Inflammatory Outcomes in the Preterm Infant

Dietary DHA (22:6n-3) is a long-chain PUFA that has provocative effects on inflammatory signal events that could potentially affect preterm infant health. It is well known that the essential fatty acid of the (n-3) series; α-linolenic acid (18:3n:3) can be desaturated and elongated in the liver endoplasmic reticulum and peroxisome to produce the 22-carbon DHA. Nevertheless, concern exists as to the efficiency of this mechanism in providing the preterm infant with adequate DHA. Activity of the δ-6-desaturase and the δ-5-desaturase necessary for DHA synthesis is decreased by protein deprivation. The combined effects of suboptimal intake of both DHA and protein in the preterm infants could have substantial clinical consequences.

Branched-chain fatty acid composition of human milk and the impact of maternal diet: the Global Exploration of Human Milk (GEHM) Study

BACKGROUND An understudied component of the diet, branched-chain fatty acids (BCFAs) are distinctive saturated fatty acids that may have an important influence on health. Human-milk fatty acid composition is known to differ worldwide, but comparative data are lacking on BCFAs. OBJECTIVE We tested the hypotheses that concentrations of BCFAs in human milk differ between populations and are associated with maternal diet. DESIGN We surveyed the BCFA composition of samples collected as part of a standardized, prospective study of human-milk composition. Mothers were enrolled from 3 urban populations with differing diets: Cincinnati, Ohio; Shanghai, China; and Mexico City, Mexico. Enrollment was limited to healthy mothers of term singleton infants. We undertook a cross-sectional analysis of milk from all women with samples at postpartum week 4 (n = 359; ∼120 women/site). Fatty acids were extracted from milk by using a modified Bligh-Dyer technique and analyzed by gas chromatography. Statistical analysis was performed by ANOVA and Tobit regression. For Cincinnati mothers, 24-h diet recalls were analyzed in relation to the individual BCFA concentrations measured in milk samples. RESULTS Total BCFAs in milk differed by site, with the highest concentration in Cincinnati followed by Mexico City and Shanghai (mean ± SE: 7.90 ± 0.41, 6.10 ± 0.36, and 4.27 ± 0.25 mg/100 mL, respectively; P < 0.001). Site differences persisted after delivery mode, maternal age, and body mass index were controlled for. The individual concentrations of iso-14:0, iso-16:0, iso-18:0, anteiso-15:0, and anteiso-17:0 also differed between sites. Milk concentrations of iso-14:0 and anteiso-15:0 were associated with maternal intake of dairy; iso-16:0 was associated with maternal intakes of dairy and beef. CONCLUSIONS BCFA concentrations in milk at 4 wk postpartum differed between mothers from Cincinnati, Shanghai, and Mexico City. Variations in human-milk BCFAs are influenced by diet. The impact of BCFAs on infant health warrants investigation.