Sarah N. Taylor

Host factors in amniotic fluid and breast milk that contribute to gut maturation.

The gut represents a complex organ system with regional differences, which reflect selective digestive and absorptive functions that change constantly in response to bodily requirements and the outside milieu. As a barrier to the external environment, gut epithelium must be renewed rapidly and repeatedly. Growth and renewal of gut epithelial cells is dependent on controlled cell stimulation and proliferation by a number of signaling processes and agents, including gut peptides—both endogenous and exogenous sources. This cascade of events begins during fetal development; with the ingestion of amniotic fluid, this process is enhanced and continued during infancy and early childhood through the ingestion of human milk. Events influenced by amniotic fluid during fetal development and those influenced by human milk that unfold after birth and early childhood to render the gut mature are presented.

Vitamin D and Its Role During Pregnancy in Attaining Optimal Health of Mother and Fetus

Despite its discovery a hundred years ago, vitamin D has emerged as one of the most controversial nutrients and prohormones of the 21st century. Its role in calcium metabolism and bone health is undisputed but its role in immune function and long-term health is debated. There are clear indicators from in vitro and animal in vivo studies that point to vitamin D’s indisputable role in both innate and adaptive immunity; however, the translation of these findings to clinical practice, including the care of the pregnant woman, has not occurred. Until recently, there has been a paucity of data from randomized controlled trials to establish clear cut beneficial effects of vitamin D supplementation during pregnancy. An overview of vitamin metabolism, states of deficiency, and the results of recent clinical trials conducted in the U.S. are presented with an emphasis on what is known and what questions remain to be answered.

Intestinal Permeability in Preterm Infants by Feeding Type: Mother's Milk Versus Formula

BACKGROUND AND OBJECTIVE Intestinal permeability in preterm infants represents a critical balance between absorption of nutritional agents and protection from dangerous pathogens. This study identified the relationship between feeding type (human milk and formula) and intestinal permeability as measured by lactulose to mannitol ratio in preterm infants in the first postnatal month. STUDY DESIGN Sixty-two preterm (<or=32 weeks of gestation) infants had assessment of feeding type and evaluation with enteral lactulose and mannitol administration and urinary measurement at three time points in the first postnatal month. RESULTS Infants who received the majority of feeding as human milk (>75%) demonstrated significantly lower intestinal permeability when compared to infants receiving minimal or no human milk (<25% or none) at postnatal days 7, 14, and 30 (p = 0.02, 0.02, and 0.047, respectively). When infants receiving any human milk were compared to infants receiving formula only, a significant difference existed at day 7 and day 14 but not for day 30 (p = 0.04, 0.02, and 0.15, respectively). With evaluation over the complete study period, exclusively formula-fed infants demonstrated a 2.8-fold higher composite median lactulose/mannitol ratio when compared with those who received any human milk. Infants who received >75% of enteral feeding as mothers milk demonstrated a 3.8-fold lower composite median ratio when compared to infants receiving <25% or no mothers milk. CONCLUSION Preterm infant intestinal permeability was significantly decreased for those receiving human milk versus formula in a dose-related manner in the first postnatal month.

Maternal Versus Infant Vitamin D Supplementation During Lactation: A Randomized Controlled Trial

OBJECTIVE: Compare effectiveness of maternal vitamin D3 supplementation with 6400 IU per day alone to maternal and infant supplementation with 400 IU per day. METHODS: Exclusively lactating women living in Charleston, SC, or Rochester, NY, at 4 to 6 weeks postpartum were randomized to either 400, 2400, or 6400 IU vitamin D3/day for 6 months. Breastfeeding infants in 400 IU group received oral 400 IU vitamin D3/day; infants in 2400 and 6400 IU groups received 0 IU/day (placebo). Vitamin D deficiency was defined as 25-hydroxy-vitamin D (25(OH)D) <50 nmol/L. 2400 IU group ended in 2009 as greater infant deficiency occurred. Maternal serum vitamin D, 25(OH)D, calcium, and phosphorus concentrations and urinary calcium/creatinine ratios were measured at baseline then monthly, and infant blood parameters were measured at baseline and months 4 and 7. RESULTS: Of the 334 mother-infant pairs in 400 IU and 6400 IU groups at enrollment, 216 (64.7%) were still breastfeeding at visit 1; 148 (44.3%) continued full breastfeeding to 4 months and 95 (28.4%) to 7 months. Vitamin D deficiency in breastfeeding infants was greatly affected by race. Compared with 400 IU vitamin D3 per day, 6400 IU/day safely and significantly increased maternal vitamin D and 25(OH)D from baseline (P < .0001). Compared with breastfeeding infant 25(OH)D in the 400 IU group receiving supplement, infants in the 6400 IU group whose mothers only received supplement did not differ. CONCLUSIONS: Maternal vitamin D supplementation with 6400 IU/day safely supplies breast milk with adequate vitamin D to satisfy her nursing infant’s requirement and offers an alternate strategy to direct infant supplementation.

Neonatal vitamin D status at birth at latitude 32°72′: evidence of deficiency

Objective:With vitamin D deficiency as a serious public health problem, vitamin D status at birth was measured in neonates at latitude 32°72′ (southeastern United States).Study Design:In umbilical cord blood, vitamin D status, demonstrated by circulating 25-hydroxyvitamin D, was measured and related to race and season of birth.Result:The mean±standard deviation of 25-hydroxyvitamin D in 100 cord blood samples was 13.5±8.3 ng/ml for the cohort. African-American infants, with a mean±standard deviation of 10.5±6.0 ng/ml, demonstrated significantly lower vitamin D status than Caucasian infants, with a mean±standard deviation of 19.5±9.6 ng/ml (P<0.0001). By season, the mean 25-hydroxyvitamin D level at birth in November–March compared to April–October was 11.3 ng/ml lower in Caucasian infants (from 29.0 to 17.7 ng/ml) and 3 ng/ml lower in African-American infants (from 13.1 to 10.1 ng/ml).Conclusion:The prevalence of vitamin D insufficiency is high in this cohort. African-American infants demonstrate significantly lower vitamin D status at birth than Caucasian infants. Seasonality, while significant in both groups, had a greater impact on the vitamin D status of Caucasian newborns.

Vitamin D Supplementation during Lactation to Support Infant and Mother

How human milk as the ideal infant nutrition lacks vitamin D activity leading to the severe bony deformities and muscle weakness of rickets has stymied scientists and clinicians for centuries. Recent understanding of human vitamin D requirements based on functional indicators of vitamin D activity demonstrate that the majority of humans, including lactating mothers, subsist in a vitamin D insufficient state. In this state, human milk provides inadequate vitamin D supply to the nursing infant. In contrast, with achieving maternal vitamin D sufficiency, human milk attains vitamin D activity equivalent to present infant oral supplementation. Current investigation of the role of vitamin D in diseases beyond bone health is revealing the significance of early life vitamin D sufficiency in establishing lifelong health.

Circulating 25-hydroxyvitamin d levels in fully breastfed infants on oral vitamin d supplementation.

Objective. To examine the effectiveness of oral vitamin D3 (400 IU) supplementation on the nutritional vitamin D status of breastfeeding infants. Design. As part of a larger ongoing vitamin D RCT trial of lactating women, infants of mothers assigned to control received 1 drop of 400 IU vitamin D3/day starting at one month of age. Infant 25(OH)D levels (mean ± S.D.) were measured by RIA at visits 1, 4, and 7. Results. The infant mean ± S.D. 25(OH)D at baseline was 16.0 ±9.3 ng/mL (range 1.0–40.8; n = 33); 24 (72.7%) had baseline levels <20 ng/mL (consistent with deficiency). The mean levels increased to 43.6 ±14.1 (range 18.2–69.7) at 4 months and remained relatively unchanged at month 7: 42.5 ±12.1 ng/mL (range 18.9–67.2). The change in values between 1 and 4 months and 1 and 7 months was statistically significant (P ≤ .0001), and despite a decrease in dose per kilogram, values were not significantly different between months 4 and 7 (P = .66). Conclusions. Oral vitamin D3 supplementation as an oil emulsion was associated with significant and sustained increases in 25(OH)D from baseline in fully breastfeeding infants through 7 months.

Early enteral feeding in very low birth weight infants.

BACKGROUND/AIM Debate exists about when to initiate enteral feeding (EF) in very low birth weight (VLBW) preterm infants. This retrospective study compared the effectiveness of an education-based quality improvement project and the relationship of time of the first EF to necrotizing enterocolitis (NEC) or death incidence and parenteral nutrition (PN) days in VLBW infants. STUDY DESIGN/SUBJECTS VLBW infants born in 2 epochs were compared for hour of the first feed, PN days, NEC or death incidence, and feeding type. The 2 epochs were temporally divided by a quality improvement initiative to standardize initiation of EF in postnatal hours 6-24. RESULTS 603 VLBW infants were included. Median time of feed initiation decreased from 33 (Epoch 1) to 14h (Epoch 2) (p<0.0001). Median PN days were 14 vs. 12, respectively (p=0.07). The incidence of NEC or death was 13.4% vs. 9.5%, respectively (p=0.14). When controlling for birth weight, gestational age, race, gender, and time period, earlier feed initiation was associated with decreased NEC or death (p=0.003). Evaluation of the relationship of early EF (defined as within the first 24h) in Epoch 2 alone showed that early EF was significantly associated with decreased NEC or death (6.3 vs 15.1%) (RR, 95% CI=0.28, 0.13-0.58) and less PN days (p<0.0001). CONCLUSIONS In a VLBW infant cohort, an education-based process improvement initiative decreased time of EF initiation to a median of 14h with no associated increase in NEC or death. In fact, results suggest that earlier feeding is associated with decreased NEC or death.

Use of Recombinant Factor VIIa in Infants with Severe Coagulopathy

The risk of hemorrhage in infants with severe coagulopathies unresponsive to fresh frozen plasma (FFP) infusions may preclude therapeutic invasive interventional procedures. We describe the successful use of recombinant factor VIIa (rFVIIa) in two such infants, the first with cirrhosis requiring paracentesis and the second with necrotizing enterocolitis requiring laparotomy. This report reviews the current concepts on the mechanism of action of the drug rFVIIa and considers its expanded use in infants unresponsive to FFP replacement.

Refeeding syndrome in very-low-birth-weight intrauterine growth-restricted neonates.

Objective:Determine the incidence of refeeding syndrome, defined by the presence of hypophosphatemia in very-low-birth-weight (VLBW) infants with intrauterine growth restriction (IUGR) compared with those without IUGR.Study design:In this retrospective cohort study, VLBW infants admitted over a 10-year period (271 IUGR and 1982 non-IUGR) were evaluated for specific electrolyte abnormalities in the first postnatal week.Result:IUGR infants were significantly more likely to have hypophosphatemia (41% vs 8.9%, relative risk (95% confidence interval: 7.25 (5.45, 9.65)) and severe hypophosphatemia (11.4% vs 1%, 12.06 (6.82, 21.33)) in the first postnatal week. The incidence of hypophosphatemia was significantly associated with the presence of maternal preeclampsia in all VLBW infants (odds ratio (OR): 2.58 (1.96, 3.40)) when controlling for birth weight and gestational age.Conclusion:Refeeding syndrome occurs in VLBW infants with IUGR and born to mothers with preeclampsia. Close monitoring of electrolytes, especially phosphorus, is warranted in this population.