Early neutral prebiotic oligosaccharide supplementation reduces the incidence of some allergic manifestations in the first 5 years of life.

BACKGROUND: A mixture of neutral prebiotic oligosaccharides has been shown to reduce the incidence of atopic dermatitis (AD) and allergy associated symptoms during the first 2 years of life. OBJECTIVE: To evaluate if this protective effect against allergy lasted beyond the intervention period until 5 y of age. METHODS: In a prospective, double blind, placebo-controlled fashion, healthy term infants at risk of atopy were fed either a prebiotic-supplemented (0.8 g/100 ml scGOS/lcFOS) or placebo-supplemented (0.8 g/100 ml maltodextrin) hypoallergenic formula during the first 6 mo of life. Following this intervention period, follow-up continued until 5 y of life. The present study evaluated (i) the cumulative incidence of allergic manifestations during 5 y, and (ii) the prevalence of allergic and persistent allergic manifestations at 5 y. Monitored allergic manifestations were AD, recurrent wheezing, allergic rhinoconjunctivitis and urticaria. RESULTS: Ninety-two children (50 in placebo group, 42 in intervention group) completed the 5-y follow-up. The 5-y cumulative incidences of any allergic manifestation and atopic dermatitis were significantly lower in the scGOS/lcFOS group (30.9, 19.1 %, respectively) compared to placebo group (66, 38 %, respectively) (p< 0.01 and< 0.05). Children in the scGOS/lcFOS group tended to have a lower incidence of allergic rhinoconjunctivitis, and allergic urticaria (4.8 vs 16% for both manifestations, p=0.08). There was no difference in the cumulative incidence of recurrent wheezing. With regard to the prevalences at 5 y, intervention group had significantly lower prevalence of any persistent allergic manifestation and rhinoconjunctivitis (4.8, 2.4 %, respectively) compared to placebo (26, 14 %, respectively) (p < 0.01 and =0.05). Prevalence of persistent AD tended to be lower in the intervention group (2.4 vs 12%, p= 0.09). Although intervention group had 75% reduction in the prevalence of persistent wheezing (4.8 vs 14 %), no significance was shown. CONCLUSION: Oligosaccharide prebiotics (scGOS/lcFOS), when started early in life have a protective effect against allergic manifestations in high risk infants. The protection lasts beyond infancy until 5 y of life, for AD and allergic rhinoconjunctivitis. Long-term follow-up studies in larger populations are warranted to evaluate the potential preventive effect of this mixture on asthma.

Update of adjustable fortification regimen for preterm infants: a new protocol.

Preterm infants fed fortified human milk in standard fashion receive less protein than they need due to customary assumptions. Protein is limiting for growth and neurocognitive development,and shortfalls of protein are not acceptable. Adjustable fortification regimen has been proven as an effective way to provide adequate protein intakes and appropriate growth in this group of infants. Italian Association of Human Milk Banks (AIBLUD) has promoted and implemented this Adjustable fortification regimen in neonatal intensive care units (NICUs) with success. This paper presents an update of Adjustable fortification regimen; a new protocol already utilized in several italian NICUs.

Amendment to 2010 Italian guidelines for the establishment and operation of a donor human milk bank.

The present paper is an amendment to the recent Italian Guidelines of human milk banking published in 2010. Working Group on Guidelines (Panel) of the Italian Association of Human Milk Banks (AIBLUD) states, in accordance with the European Union Comission's Amending Directive of January 2011, that the hard plastic feeding bottles used in the collection, storage and pasteurization of the human milk should be Bisphenol A (BPA) free. Until new evidence are available polycarbonate feeding bottles should not be used for collection, storage and pasteurization of human milk. The paper summarizes the former and current European Commission Directives and shows the related amending changes to the 2010 Italian Human Milk Banking Guidelines.

Preterm infants fed fortified human milk receive less protein than they need.

OBJECTIVE: The aim of this study was to compare the actual nutrient intakes observed in a previously reported study with assumed nutrient intakes based on the customary assumptions about the composition of human milk. STUDY DESIGN: Fortified human milk is assumed to provide adequate amounts of nutrients for premature infants. This assumption holds if milk has the composition of milk expressed by mothers of premature infants during weeks 2 to 3 of lactation. The assumption does not necessarily hold for milk expressed after 2 to 3 weeks lactation. It also does not hold for donor milk, which is typically provided by mothers of term infants. The size of the disparity between assumed and actual nutrient intakes is not known. Actual nutrient intakes were available for 32 preterm infants participating in the study. Assumed nutrient intakes were calculated for these infants by substituting assumed nutrient concentrations for observed nutrient concentrations. Data were compared separately for each of the 3 study weeks. RESULT: Actual protein intakes were significantly and consistently lower than assumed protein intakes during each study week. The differences in mean intakes were large, ranging from 0.5 to 0.8 g kg(-1) per day. Differences in energy intake were small and not consistently significant. CONCLUSION: Actual intakes of protein by preterm infants fed fortified human milk are substantially lower than assumed intakes. The discrepancy may in part explain why preterm infants frequently show postnatal growth failure.

Adjustable fortification of human milk fed to preterm infants: does it make a difference?

BACKGROUND: Inadequate nutrition leading to growth failure is common among premature infants. Although fortified breast milk (breast milk plus commercially prepared fortifier) is the preferred feeding, nutrient intakes achieved with fortified breast milk fall short of meeting nutrient needs. This is mainly due to inadequate protein content of fortifiers and variability in composition of expressed breast milk. OBJECTIVE: A new adjustable fortification regimen has been designed to ensure that protein needs of premature infants are met at all times. The new regimen encompasses increasing the amount of fortifier and adding extra protein to breast milk guided by periodic determinations of blood urea nitrogen (BUN). The study tested the hypothesis that infants fed according to the new regimen have higher protein intakes and improved weight gain compared to infants fed according to standard fortification regimen. METHODS: In a prospective, controlled trial, preterm infants with birth weights of 600-1750 g and gestational ages between 26 and 34 weeks were fed their own mother's milk or banked donor milk or both. Infants were randomly assigned before 21 days of age to either the new adjustable fortification regimen or the standard regimen. The study period began when feeding volume reached 150 ml/kg/day and ended when infants reached a weight of 2000 g. Standard fortification (STD) consisted in the use of the recommended amount of fortifier. Adjustable fortification (ADJ) consisted in the use, in addition to standard fortification, of extra fortifier and supplemental protein guided by twice-weekly BUN determinations. The primary outcome was weight gain, with serum biochemical indicators and nutrient intakes as secondary outcomes. RESULTS: Thirty-two infants completed the study as planned (16 ADJ, 16 STD). Infants receiving the ADJ regimen had mean protein intakes of 2.9, 3.2 and 3.4 g/kg/day, respectively, in weeks 1, 2 and 3, whereas infants receiving the STD regimen had intakes of 2.9, 2.9, 2.8 g/kg/day, respectively. Infants on the ADJ regimen showed significantly greater gain in weight (17.5+/-3.0 vs 14.4+/-3.0 g/kg/day, P<0.01) and greater gain in head circumference (1.4+/-0.3 vs 1.0+/-0.3; P<0.05) than infants on the STD regimen. Weight and head circumference gain were significantly (P<0.05) correlated with protein intake. No significant correlations were found between growth parameters and intake of fat and energy. There were no significant differences between groups in BUN and other serum chemical values. In the ADJ group, BUN concentrations increased significantly (P<0.001) over time but were not significantly higher than in the STD group. CONCLUSION: Premature infants managed with the new adjustable fortification regimen had significantly higher weight and head circumference gains than infants managed with standard fortification. Higher protein intake appears to have been primarily responsible for the improved growth with the adjustable regimen. The new fortification method could be a solution to the problem of protein undernutrition among premature infants fed human milk.

Prebiotics in infant milk formulas: new perspectives.

In recent years it has become accepted that healthy human intestinal microflora may play an important part in priming the infants' systemic and mucosal immunity. Dietary modulation of the gut microbiota is a topical area of nutritional sciences and the main focus of many current functional foods such as non-digestible oligosaccharides (NDOs). Fructo-oligosaccharides (FOS) and trans-beta-galacto-oligosaccharides (TOS) have been claimed to benefit the health of the colon by selectively stimulating the growth of bifidobacteria and lactobacilli (prebiotic effect). It could be of clinical interest to manipulate colonic flora because it is supposed that specific bacteria in the gut microbial microflora could promote potentially antiallergenic processes and play a key part in atopic disease prevention. Supporting this view is the finding that analysis of the composition of the intestinal bacterial populations showed different microbial patterns between healthy and allergic individuals. Assuming that non-digestible TOS and FOS can affect the intestinal ecosystem beneficially, the opportunity for gut flora manipulation arises in bottle-fed infants. New preterm and term infant milk formulas, supplemented with a mixture of TOS and FOS as prebiotic ingredients induced a significantly higher colonization of bifidobacteria and lactobacilli. In the future, selective manipulation of the intestinal microbiota might be an approach to novel prophylactic and therapeutic intervention strategies of atopy, by redirecting allergic Th-2 responses in favour of Th-1 responses.

Effects of a new mixture of prebiotics on faecal flora and stools in term infants.

A double-blind, randomized, controlled study was performed in 90 full term infants to evaluate dose-related bifidogenic effects of a new synergistic mixture of galacto-oligosaccharides (GOS) and fructo-oligosacharides (FOS). The GOS/FOS mixture showed a dose-dependent stimulatory effect on the intestinal growth of bifidobacteria. Also stool consistency and faecal pH were positively affected.

Soy-based formulas and phyto-oestrogens: a safety profile.

Phyto-oestrogens are non-steroidal plant-derived compounds that possess oestrogenic activity and act as selective oestrogen receptor modulators (SERMs). Among the dietary oestrogens, the isoflavone class enjoy a wide-spread distribution in most of the members of the Leguminosae family, including such prominent high-content representatives as soybean. Phyto-oestrogen research has grown rapidly in recent years owing to epidemiological studies suggesting that diets rich in soy may be associated with potential health benefits. There is a paucity of data on endocrine effects of soy phytochemicals during infancy, the most sensitive period of life for the induction of toxicity. The safety of isoflavones in infant formulas has been questioned recently owing to reports of possible hormonal effects. Infants fed soy formula receive high levels of phyto-oestrogens in the form of isoflavones (genistein, daidzein and their glycosides). To date, no adverse effects of short- or long-term use of soy proteins have been observed in humans and exposure to soy-based infant formulas does not appear to lead to different reproductive outcomes than exposure to cow milk formulas. Soy formula seems to be a safe feeding option for most infants. Nevertheless, much closer studies in experimental animals and human populations exposed to phyto-oestrogen-containing products, and particularly soy-based infant formulas, are necessary.

Individualized protein fortification of human milk for preterm infants: comparison of ultrafiltrated human milk protein and a bovine whey fortifier.

BACKGROUND: To improve the nutritional management of pre-term infants, a new individualized human milk fortification system based on presupplementation milk protein analyses was evaluated. METHODS: In an open, prospective, randomized multicenter study, 32 healthy preterm infants (birth weights, 920-1750 g) were enrolled at a mean of 21 days of age (range, 9-36 days) when tolerating exclusive enteral feedings of 150 ml/kg per day. All infants were fed human milk and were randomly allocated to fortification with a bovine whey protein fortifier (n = 16) or ultrafiltrated human milk protein (n = 16). All human milk was analyzed for protein content before fortification with the goal of a daily protein intake of 3.5 g/kg. During the study period (mean, 24 days) daily aliquots of the fortified milk were obtained for subsequent analyses of the protein content. RESULTS: Both fortifiers were well tolerated, and growth gain in weight, length, and head circumference, as well as final preprandial concentrations of serum urea, transthyretin, transferrin, and albumin were similar in both groups. The ultimate estimated protein intake was equivalent in both groups (mean 3.1+/-0.1 g/kg per day). Serum amino acid profiles were similar in both feeding groups, except for threonine (significantly higher in the bovine fortifier group) and proline and ornithine (significantly higher in the human milk protein group). CONCLUSIONS: Protein analyses of the milk before individual fortification provides a new tool for an individualized feeding system of the preterm infant. The bovine whey protein fortifier attained biochemical and growth results similar to those found in infants fed human milk protein exclusively with the corresponding protein intakes.

Fortification of human milk: evaluation of a novel fortification scheme and of a new fortifier.

Human milk fed to very-low-birth-weight infants must be fortified with protein, minerals, and vitamins. We tested a new fortification regimen in which the amount of fortifier was adjusted on the basis of frequent determinations of serum urea nitrogen (SUN). A newly formulated fortifier based on bovine milk proteins was employed either in the new fashion (regimen ADJ) or in the conventional fixed proportion (regimen FIX). Using the fixed proportion, the study also compared the new fortifier with a fortifier based on human milk protein (regimen HMP). Twelve infants were studied with each of the three regimens; nearly all completed 3 weeks of study. Protein intake was generally higher in ADJ than FIX; the difference was significant (p < 0.01) during week 2. Weight gain was somewhat (but not significantly) greater in regimen ADJ (32.3 g/d or 18.8 g/kg/d) than in regimen FIX (30.0 g/d or 18.3 g/kg/d). SUN was higher in ADJ than in FIX, and several other serum chemical values (calcium, phosphorus, potassium) tended to be higher, probably reflecting higher intakes of these nutrients with ADJ than with FIX. Plasma concentrations of several amino acids were higher in ADJ than FIX, but none, including threonine, were outside the physiological range. In comparing regimen FIX to regimen HMP, infants on FIX received similar intakes of protein and showed slightly but not significantly more rapid weight gain. Concentrations of SUN were lower with FIX, but other serum chemical values, including amino acids, were generally similar to HMP. We conclude that use of the new adjustable fortification regimen is feasible and safe and that it should be studied further. It produced the expected increases in nutrient intakes and growth. The new bovine milk-based fortifier appears to be equivalent to the human milk-based fortifier.

Management of extremely low-birth-weight infants.

Better health care of women during pregnancy and delivery, improvement in neonatal intensive therapy and technology have led to a decrease in neonatal mortality and morbidity and to lower limits of birth weight and gestational age for survival. This paper refers to the management protocol used in the Department of Perinatal Pathology of the Provincial Maternity Hospital of Milan for extremely low-birth-weight (ELBW) infants (birth weight < 1000 g). In this hospital, all newborn infants presenting evidence of life, irrespective of birth weight and gestational age, are resuscitated and transferred to the Neonatal Intensive Care Unit (NICU) for clinical management. After the introduction of this protocol the mortality rate of ELBW infants dropped from 71.4% in 1977-78 to 48% in 1987-88. In a group of 72 ELBW infants with a mean birth weight of 850 g and a mean gestational age of 27 weeks, 80% presented a normal outcome, 12% presented a mild neurological impairment and 8% were affected by severe cerebral palsy at the age of two years. The intact survival of a newborn infant of 450 g at birth is also reported.

Growth and metabolic responses in low-birth-weight infants fed human milk fortified with human milk protein or with a bovine milk protein preparation.

Unfortified human milk does not normally provide enough protein to secure maximal growth in low-body-weight (LBW) infants. Due to the practical difficulties in obtaining human milk protein (HMP), a bovine milk protein preparation (BMP) was designed by computer calculation to contain as close as possible the amino acid composition of the nutritionally available human milk proteins. Twenty-one AGA, LBW infants (BW of 1,180 to 1,600 g, GA of 27 to 33 weeks) were randomly assigned to be fed HM enriched either with HMP (9 infants) or BMP (12 infants). When full volume intake (170 ml/kg/day) was reached, the protein intakes were 3.6 +/- 0.5 and 3.3 +/- 0.3 g/kg/day, respectively, in the two diet groups. During the study period of 24 days, the infants achieved intrauterine or better weight gains: 32.9 +/- 3.3 g/day (17.7 +/- 1.9 g/kg/day) in the HMP group and 34.7 +/- 7.3 g/day (18.3 +/- 3.5 g/kg/day) in the BMP group. Serum urea nitrogen, acid-base status, and albumin values were normal and similar in both groups of infants. Plasma concentrations of total essential and total amino acids at the end of the study were 3,999 and 1,539 mumol/L and 3,899 and 1,422 mumol/L in the HMP and the BMP groups, respectively. The concentrations of all individual plasma amino acids were similar in both feeding groups. These results show that feeding human milk fortified with a modified bovine milk protein preparation produces satisfactory growth and a plasma amino acid profile similar to that found in LBW infants fed exclusively human milk protein at similar intakes.