Frank Jochum

Fortification of breast milk in VLBW infants: Metabolic acidosis is linked to the composition of fortifiers and alters weight gain and bone mineralization

BACKGROUND & AIMS Study objectives were to test (a) whether increased incidence of metabolic acidosis (MA) was caused by introduction of a new commercially available fortifier for breast milk, (b) if so, whether its modification would decrease the incidence of MA and (c) to analyze the impact of MA on growth. METHODS Double-blind randomized design. Healthy breast-fed infants (≤34 gestational weeks). Primary outcome measure was incidence of MA (BE < -6.0 mmol/L). Secondary outcome measures were growth, bone mineral content (BMC), vital signs, treatment with sodium hydrogen carbonate and Ca and laboratory parameters (pH, pCO₂, HCO₃⁻, electrolytes). RESULTS Part 1 (comparison of standard (SF) and new fortifier (NF)): Interim analysis showed MA in 1 out of 7 (SF) and 7 out of 8 (NF) infants, p = 0.01; therefore the study was interrupted; subsequently the fortifier was adapted by modifying mineral components. Part 2 (comparison of SF and reformulated fortifier (RF)): MA occurred in 3 out of 15 (SF) and 6 out of 19 (RF), p = 0.7. When data of all infants studied, those with MA had lower mean weight gain (median: 9 vs. 21 g/kg/d, p < 0.01) and lower BMC (1.6% vs. 1.9% BMC/lean, p = 0.04) at discharge. CONCLUSIONS When fed fortified breast milk, mild MA spontaneously may develop in 20-30% of VLBW infants. A fortifier with an inappropriate composition may increase the severity and frequency of MA. Our data show that weight gain and BMC seem to be related to acid-base homeostasis. It may be speculated that inadequate growth of fully fed preterm infants is triggered more often by imbalances of acid-base status than previously expected.

Water, Sodium, Potassium and Chloride

The sudden disruption of excessive placental supply with fluids and electrolytes is challenging for neonatal physiology during the period of postnatal adaptation. Different from many other nutrients, the body experiences large changes in daily requirements during the first 7-14 postnatal days, and on the other hand does not tolerate conditions of excess and deficiency very well. Imbalances of fluid and electrolytes are common in neonates, which--in addition--might be further aggravated by NICU treatment procedures. Therefore, fluid and electrolyte management can be one of the most challenging aspects of neonatal care of the premature infant. An understanding of the physiological adaptation process to extrauterine life--and how immaturity effects that transition--is the basis which is needed to understand and manage fluid and electrolyte balance in premature infants. This chapter addresses the physiology of postnatal adaptation and other aspects of fluid and electrolyte management (concerning potassium, sodium and chloride) of the preterm infant.

Neonatology/paediatrics - guidelines on parenteral nutrition, chapter 13.

There are special challenges in implementing parenteral nutrition (PN) in paediatric patients, which arises from the wide range of patients, ranging from extremely premature infants up to teenagers weighing up to and over 100 kg, and their varying substrate requirements. Age and maturity-related changes of the metabolism and fluid and nutrient requirements must be taken into consideration along with the clinical situation during which PN is applied. The indication, the procedure as well as the intake of fluid and substrates are very different to that known in PN-practice in adult patients, e.g. the fluid, nutrient and energy needs of premature infants and newborns per kg body weight are markedly higher than of older paediatric and adult patients. Premature infants <35 weeks of pregnancy and most sick term infants usually require full or partial PN. In neonates the actual amount of PN administered must be calculated (not estimated). Enteral nutrition should be gradually introduced and should replace PN as quickly as possible in order to minimise any side-effects from exposure to PN. Inadequate substrate intake in early infancy can cause long-term detrimental effects in terms of metabolic programming of the risk of illness in later life. If energy and nutrient demands in children and adolescents cannot be met through enteral nutrition, partial or total PN should be considered within 7 days or less depending on the nutritional state and clinical conditions.

Total glutamine content in human milk is not influenced by gestational age

Background: Glutamine may be a conditionally indispensable amino acid in neonates and should be given in adequate amounts. Reliable information concerning the glutamine content of human milk is lacking. Aim: To assess total glutamine content in human milk using a novel analytical procedure, and to evaluate the potential influence of time of delivery and lactational stage. Methods: The content of free and protein‐bound glutamine was assessed in transitional (days 4–7 of lactation) and mature (days 29–34) human milk, after preterm (<35 wk of gestation, n=20) or term (>37 wk, n=20) delivery. Milk samples were obtained by manual expression and stored at ≤70°C. Measurement of protein‐bound glutamine was performed after stabilization by bis(1,1‐trifluoroacetoxy)iodobenzene (BTI). Free glutamine was detected by HPLC. Results: There was no difference concerning glutamine content in human milk after term or preterm delivery (median of 5000 vs 4960 µmol/l milk). The protein‐bound glutamine content decreased with the duration of lactation (6230 vs 4540 µmol/l milk). Free glutamine accounted for only 3–10% of the protein‐bound glutamine content. The free glutamine content showed a high variability after preterm and term delivery.

Use of bioelectrical impedance analysis and anthropometry to measure fat-free mass in children and adolescents with Crohn disease.

Objectives: To investigate the precision of published prediction equations for fat-free mass (FFM) from bioimpedance measurements in children with Crohn disease using dual-energy X-ray absorptiometry (DXA) as an in vivo gold standard. Methods: Fat-free mass of 49 white boys and girls ages 7.3 to 16.9 y suffering from Crohn disease was measured by DXA. Body weight, height and bioimpedance measurements were also collected. FFM measured by DXA (FFMDXA) was compared with FFM predicted by the only 5 published prediction equations available for children and adolescents. An equation was developed for predicting FFM and was validated using a bootstrap method. Results: When correlating predicted FFM with FFMDXA, Schaefers equation showed the highest R2 (0.950), the smallest standard error of estimate (SEE) (2.05 kg) and the smallest percentage error (0.28%). Our prediction equation for estimating FFM was FFM = 0.652 Ht2/Z + 0.0385 Wt + 0.586 Age − 0.327, R2 = 0.951, SEE = 2.08, P < 0.0005, where Ht2/Z is the impedance index in cm2/Ω, Wt is body weight in kilograms, age is in years. R2 value from bootstrap method was 0.950 ± 0.01 (95% confidence interval 0.927–0.968), indicating an acceptable validation of the derived formula. Conclusions: The formula of Schaefer is the best for predicting FFM. The present study provides a new prediction equation for estimating FFM in children with Crohn disease that may be used in clinical settings in which more sophisticated body composition measuring equipments are not available.

Early or Late Parenteral Nutrition in Critically Ill Children: Practical Implications of the PEPaNIC Trial

come) may have been biased. A 3 days shorter duration of mechanical ventilation ( p = 0.01) and a 4.1 day shorter hospital stay ( p = 0.005) were also observed with EarlyPN. Mortality was similar in both groups, but hypoglycemia was more frequent with LatePN (9.1%) vs. EarlyPN (4.8%, p = 0.001). The authors conclude that withholding PN for 1 week is advantageous in critically ill children. Based on the previous experience with the EPaNIC trial in adult ICU patients [6] , we consider it likely that these findings will invigorate the controversy about potential harm of early sPN. However, several important points and questions related to the PEPaNIC trial arise, including the selection and heterogeneity of included patients and the choices taken regarding nutrition and glucose control management.

Werbebeschränkungen für Säuglingsanfangs- und Folgenahrungen

ZusammenfassungFür die Vermarktung von Säuglingsanfangs- und Folgenahrungen gelten gesetzliche Beschränkungen mit dem Ziel, das Stillen zu fördern und zu schützen. Idealisierende Abbildungen oder Textaussagen, die den Eindruck einer Ähnlichkeit der Flaschenernährung mit dem Stillen erwecken könnten, sind untersagt. Für die Bewerbung von Säuglingsanfangsnahrungen gelten striktere Regeln als für Folgenahrungen. Säuglingsanfangs- und Folgenahrungen sind sich in ihrer Zusammensetzung sehr ähnlich und werden mit nahezu gleicher Packungsgestaltung und Auslobung angeboten. Werbung für eine Folgenahrung bewirkt deshalb auch unmittelbar eine Bewerbung der entsprechenden Säuglingsanfangsnahrung und birgt das Risiko, den Stillerfolg und die Stilldauer nachteilig zu beeinflussen. Die Ernährungskommissionen der Deutschen Gesellschaft für Kinder- und Jugendmedizin (DGKJ) und Österreichischen Gesellschaft für Kinder- und Jugendheilkunde sprechen sich deshalb dafür aus, an Familien und die breite Öffentlichkeit gerichtete Werbung für Folgenahrungen für Säuglinge in gleicher Weise einzuschränken, wie es das europäische und das nationale Recht für Säuglingsanfangsnahrungen vorsieht. In der deutschen Verordnung über diätetische Lebensmittel und im Sachverständigengutachten Österreichisches Lebensmittelbuch sollten die Bestimmungen zu Werbemaßnahmen für Säuglingsanfangs- und Folgenahrungen gleichlautend gestaltet werden.AbstractMarketing of infant formula and follow-on formula is restricted by legislation aiming at protection, promotion and support of breastfeeding. Graphics and text that may idealize infant formula and bottle feeding or may suggest similarity with breastfeeding are prohibited. Stricter rules are in place for marketing of infant formula than for follow-on formula. Infant formula and follow-on formula have a very similar composition and are marketed with almost identical packaging and wording. Therefore, advertising follow-on formula will also directly promote the respective infant formula and bears the risk of having adverse effects on breastfeeding rates and duration. The Committees on Nutrition of the German and Austrian Societies of Pediatrics support similar restrictions for the marketing of follow-on formula to families and to the general public as they have been defined for infant formula in the European and national legislations. The relevant regulations in the German and Austrian dietetic food legislations on marketing of follow-on formula should be adapted to the standards on marketing of infant formula.

Impedance index or standard anthropometric measurements, which is the better variable for predicting fat-free mass in sick children?

Aim: To compare the predictive value of impedance index (ZI, height2/impedance) with anthropometric measurements for estimating fat‐free mass (FFM).

Warnung vor Verwendung unzureichend geprüfter Muttermilch

In Deutschland wird derzeit der kommerzielle Vertrieb von humaner Milch als Spendermilch etabliert und propagiert. Die Ernährungskommission der Deutschen Gesellschaft für Kinderund Jugendmedizin (DGKJ) warnt vor den Gefahren der Verwendung unzureichend geprüfter Spendermilch, da verbindlich geregelte, qualitätsgesicherte Kontrollen dieser Milch nicht vorgenommen werden und erhöhte Risiken durch die kommerziellen Anreize für die Verkäuferinnen bestehen. Die beste Wahl für die Ernährung eines gesunden Säuglings ist zweifellos das Stillen [1]. Stillen bietet vielfältige Vorteile, wie z. B. eine bedarfsgerechte Nährstoffzufuhr, eine Verminderung des Risikos für das Auftreten von Infektionen beim gestillten Säugling [2–5] und positive langfristige Wirkungen wie z. B. eine Risikoreduktion für Übergewicht und Adipositas sowie eine bessere spätere kognitive Leistungsfähigkeit [2, 3, 5–8]. Mit der Verwendung von nicht umfassend kontrollierter humaner Milch zur Ernährung fremder Säuglinge sind jedoch für den Empfänger unkontrollierbare Risiken verbunden. So können über humane Milch nicht nur multiple Infektionserkrankungen, wie Humane-Immundefizienz-Virus(HIV)-Infektion oder Hepatitis, von der Spenderin auf den mit Spendermilch ernährten Säugling übertragen werden [9, 10], sondern auch Fremdstoffe und Wirkstoffe aus Medikamenten, die von der Spenderin eingenommen wurden [11]. Je nach Wirkstoff und Dosierung können dadurch eingreifende Schäden beim Säugling verursacht werden wie z. B. Atempausen oder lebenslang begleitende Organschäden. Außerdem ist die Zusammensetzung der humanen Milch von Ernährung und Ernährungszustand der Spenderin abhängig [12], sodass hierdurch weitere, schwer kontrollierbare Risiken für den durch humane Spendermilch ernährten Säugling bestehen. Darüber hinaus kann der finanzielle Anreiz für die Verkäuferin zu einem erhöhten Risiko der Kontamination durch Alkohol, Tabakbestandteile oder auch illegale Drogen mit potenziell bedrohlichen Auswirkungen führen, so wie dies bei vergüteten Blutspenden aufgetreten ist [13].

ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Vitamins

Background: Previous guidelines on Paediatric Parenteral Nutrition (PN) were published in 2010, by the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), supported by the European Society of Paediatric Research (ESPR) were published. The aim of the present paper was to provide up-to-date evidence for health professionals working with infants, children and adolescents receiving PN. Methods: The current document is a revision of the 2005 guidelines produced by the same 3 organizations (ESPEN, ESPGHAN, ESPR) together with the Chinese Society of Parenteral and Enteral Nutrition (CSPEN). Experts participating in the guideline updating process were all professionals with extensive experience in managing PN from a wide range of European countries, Israel and China. The guideline development process was coordinated by a guideline steering committee. Each chapter of the guideline was prepared by a separate author group. These author groups were responsible for screening titles and abstracts identified by a systematic literature search for inclusion, for conducting additional expert searches (including secondary sources such as other published valid guidelines), for evaluating the quality of studies included in the given chapter and assigning evidence levels to the literature. Based on the evidence level of included studies experts formulated and graded recommendations. A consensus conference was held in February 2015. All chapter manuscripts were revised following the recommendations of the consensus conference and then reviewed and edited by the project steering committee. Final consensus on each individual guideline and its individual recommendations was achieved and assessed by online voting. This process lasted until January 2018. Funding for the consensus conference (including travel expenses for participants) was provided by all participating societies. No other funding was received for the guideline updating process and participants received no payment. Support was provided by the Hungarian Cochrane organization. Results/conclusions: The present document provides guideline for the use of PN across the wide range of pediatric patients, ranging from extremely premature infants up to teenagers weighing up to and over 100 kg [1]. It covers their individual macro- and micronutrient needs [2], [3], [4], [5], [6], [7], [8], fluid requirements [9], venous access [10], organizational aspects [11], home parenteral nutrition [12], standardized vs. individualized PN [13], and last but not least a wide range of safety considerations for prevention and management of complications such central line associated bloodstream infections (CLABSI) [14].