Detection of bovine alpha-S1-casein in term and preterm human colostrum with proteomic techniques.

Due to increased social awareness of allergens and population hyper-sensitization, the reported incidence of allergic reactions to food allergens has increased over the past two decades. Cow's milk proteins (CMPs) are among the most common food allergens. The aim of this study was to use proteomics techniques to investigate cow's milk allergens in both full-term human colostrum and in preterm newborns mothers where both groups showed no prior allergen detection -- in order to understand whether cows milk allergens could be a cause of sensitization established through lactation. The most relevant finding was the detection of the intact bovine alpha-S1-casein in both term and preterm colostrum. Using techniques detailed in this paper and which allowed for direct protein identification, beta-lactoglobulin was not detected in any of the colostrum samples. According to our results, bovine alpha 1 casein is considered a major cow's milk allergen, is readily secreted in human milk, and so could be considered a possible cause of sensitization in exclusively breastfed infants.

Twinning as a risk factor for neonatal acute intestinal diseases: a case-control study.

Introduction: Acute intestinal diseases (AID), including necrotizing enterocolitis and spontaneous intestinal perforation, are a group of conditions that typically present in preterm infants, and are associated with an elevated mortality and morbidity rate. The risk factors for these diseases remain largely unknown. The aim of the study is to identify the correlation between twinning and the development of AID. Methods: A single-center retrospective case-control study was conducted. We recruited all infants with a diagnosis of AID, confirmed by anatomopathology, recovered in NICU between 2010 and 2020. Considering the rarity of the outcome, 4 matched controls for each subject were randomly chosen from the overall population of newborns. Odds Ratio (OR) and 95% Confidence Interval (CI) were calculated using a conditional logistic regression model and a multivariate model by the creation of a Directed Acyclic Graph (www.dagitty.net). Results: The study population resulted in 65 cases and 260 controls. The two groups present similar median gestational age and mean birthweight in grams. The cases have a higher frequency of neonatal pathology (defined as at least one of patent ductus arteriosus, early or late sepsis, severe respiratory distress) (84.6% vs. 51.9%), medically assisted procreation (33.8% vs. 18.8%) and periventricular leukomalacia (10.8% vs. 2.7%), and a lower frequency of steroids prophylaxis (67.7% vs. 86.9%). About 50% of cases needed surgery. The OR for the direct effect were difference from one using logistic regression booth without and with repeated measures statements: from 1.14 to 4.21 (p = .019) and from 1.16 to 4.29 (p = .016), respectively. Conclusions: Our study suggests that twinning may be a risk factor for the development of AID. Due to the small number of cases observed, further studies on larger populations are needed.

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.

Biological, nutritional and clinical aspects of feeding preterm infants with human milk.

Benefits of breastfeeding are widely recognized, during the last decades human milk has been identified as the normative standard for infant feeding and nutrition. Recent evidence focused on specific bioactive and immunomodulatory factors, such as oligosaccharides, lactose, glycosaminoglycans of human milk and the variability of their concentrations during lactation in both term and preterm milk. Human milk should be fortified with proteins, minerals and vitamins to ensure optimal nutrient intake for preterm VLBWI infants. Best fortification strategies as well as the optimal composition of fortifiers are still object of research. Short and long-term clinical, metabolic, immunologic and neurodevelopmental advantages of breastfeeding ndividualizes fortification - particulary adjustable fortification- has proven to be effective when compared to formula are well documented. Moreover several non-experimental studies observed that clinical feeding tolerance is improved and the attainment of full enteral feeding is quicker by a diet of human milk. In addition, benefits of breastfeeding on psychological and relational aspects have to be considered. Mother’s own milk remains the first choice for all neonates, when it is not available or not sufficient despite significant lactation support, donor milk represents the second best alternative and although some nutritional elements are inactivated by the pasteurization process, it still has documented advantages compared to formula.

Donor human milk versus mother's own milk in preterm VLBWIs: a case control study.

As for term infants, over the past decades there has been increasing evidence of the benefits of human milk in the feeding of Very Low Birth Weight Infants (VLBWI), influencing not only short-term health outcomes but also long-term neurodevelopmental, metabolic outcomes, and growth. Mother's own milk is the first choice for all neonates including preterm infants, when it is unavailable or in short supply, pasteurized donor breast milk offers a safe alternative and is considered the next best choice. The main aim of this case-control retrospective analysis was to evaluate short term advantages of mother's own milk as a sole diet compared to donor milk as a sole diet, in terms of growth, antiinfectious properties, feeding tolerance, NEC and ROP prevention in a population of VLBWI born in a tertiary center. We did not find significant differences in clinical outcome from mother's own milk compared with pasteurized donor milk. Only a slight and statistically not significant difference in growth could be observed, in favour of maternal milk. We conclude that the maximum effort should always be put in supporting and promoting breastfeeding and donor milk used not only as an alternative to mother's milk but also as a breastfeeding promotion and support strategy.

Communication in NICUs.

In a Neonatal Intensive Care Unit (NICU) counseling should be a shared culture for all the care givers: it should be developed by all the professionals, to face up to parents' needs of information, explanations, facility of decisions, finding of resources, agreement, help, reassurance, attention. The first essential aspect is the training in counseling skills, by periodic courses for all professionals of the department (physicians, nurses, and physiotherapists). In our department, a professional counselor is present, assisting the medical staff in direct counseling. The counselor's intervention allows a better parent orientation in the situation. A more effective sharing of these rules also facilitates the communication among parents and medical staff. Periodic meetings are established among the medical staff, in which the professional counselor discusses difficult situations to share possible communicative strategies. We wanted to have not only a common communicative style, but also common subjects, independent from the characteristics of each of us. Individuals are often faced with different situations. For every setting that we more frequently face in communication (for example the first interview with a parent of a very preterm infant) we have built an 'algorithm' that follows a pattern: (1) information always given; (2) frequent questions from parents; and (3) frequent difficulties in the communication. Counselling is also a tool to face some critical issue, such as the decision to open the department to parents 24 h on 24, or the promotion of mother's milk use in Very Low Birth Weight Infants (VLBWI).

Auxological evaluation of newborns.

Auxological evaluation of the newborn should be based on accurate anthropometry at birth and a reliable estimate of gestational age (GA). However, a comprehensive evaluation of the neonate should consider not only anthropometric traits at birth, but also fetal ultrasound biometry and Doppler velocimetry. Many charts have been proposed, but they are hardly comparable with each other, due to numerous methodological problems. The Italian Societies of Neonatology, of Pediatric Endocrinology and Diabetology and the Italian Society of Medical Statistics and Clinical Epidemiology promoted a multicenter survey with the aim to produce an Italian neonatal anthropometric reference (Italian Neonatal Study [INeS] charts) fulfilling the set of the criteria that a reliable neonatal chart should possess. In order to construct an international standard, an international project (INTERGROWTH-21st) has started a study aiming to create a prescriptive standard. Until an international standard is developed, the use of national updated reference charts is recommended.

Medication and breastfeeding.

It is well accepted that the best feeding method for infants is breastfeeding, due to its numerous biological and clinical effects on child and maternal health. The use of medication by the nursing mother and the physician's advice to stop nursing are the most common reasons for the cessation of breastfeeding. The physician plays an extremely delicate role and should be able to assess risks and benefits for both mother and child. The main factors that must be taken into account include pharmacokinetics, the duration of maternal therapy, the age of the infant and the general health of the infant. All physicians should have access to reliable and updated information on medication safety during breastfeeding (reference books, online medical literature). Few drugs have been demonstrated to be absolutely contraindicated during breastfeeding. Nevertheless clear, safe and reliable information is still lacking for most drugs and it would be desirable to improve the knowledge about mechanisms and consequences of infant exposure to drug present in milk.

Critical appraisal of different anthropometric charts to evaluate postnatal growth of preterm infants.

Preterm infants' survival has greatly increased in the last few decades thanks to the improvement in obstetrical and neonatal care. The correct evaluation of postnatal growth of these babies is nowadays of primary concern, although the definition of their optimal postnatal growth pattern is still controversial. Concerns have also been raised about the strategies to monitor their growth, specifically in relation to the charts used. At present, the charts available in clinical practice are fetal growth charts, neonatal anthropometric charts and postnatal growth charts for term infants. None of these, for different reasons, is suitable to correctly evaluate preterm infant growth. Recently, an international project has recently started aiming to create prescriptive standard for the evaluation of postnatal growth of preterm infants (INTERGROWTH-21st). Alternatively, at present, while specific charts for evaluating preterm infant postnatal growth are lacking, the best compromise is likely to be as follows: from birth to term neonatal anthropometric charts; International longitudinal charts WHO 2006 or CDC 2002 from term to childhood.

Cow's milk proteins in human milk.

Cow's milk proteins (CMPs) are among the best characterized food allergens. Cow's milk contains more than twenty five different proteins, but only whey proteins alpha-lactalbumin, beta-lactoglobulin, bovine serum albumin (BSA), and lactoferrin, as well as the four caseins, have been identified as allergens. Aim of this study was to investigate by proteomics techniques cow's milk allergens in human colostrum of term and preterm newborns' mothers, not previously detected, in order to understand if such allergens could be cause of sensitization during lactation. Term colostrum samples from 62 healthy mothers and preterm colostrum samples from 11 healthy mothers were collected for this purpose. The most relevant finding was the detection of the intact bovine alpha-S1-casein in both term and preterm colostrum. Using this method, which allows direct proteins identification, beta-lactoglobulin was not detected in any of colostrum samples. According to our results bovine alpha 1 casein that is considered a major cow's milk allergen is readily secreted in human milk: further investigations are needed in order to clarify if alpha-1-casein has a major role in sensitization or tolerance to cow's milk of exclusively breastfed predisposed infants.

Congenital cytomegalovirus infection and audiological follow-up: electrophysiological auditory threshold before 3 months of age as a predictor of hearing outcome at 3 years of age.

OBJECTIVE: We aimed to evaluate whether electrophysiological auditory thresholds (EATs) before 3 month of age, as assessed by the auditory brainstem responses (ABR) test and the auditory steady state responses (ASSR) test, can predict hearing outcome at 3 years of age among children born with congenital cytomegalovirus (cCMV) infection. STUDY DESIGN: Audiological assessment was performed before 3 months of age, and every 6 months thereafter until 3 years of age, in a population of 63 children (126 ears). EATs before 3 months of age and at 3 years of age were compared. RESULT: No ear with an EAT of ≤30 dBHL (i.e. normal hearing) before 3 months of age showed worsening EATs at 3 years of age. CONCLUSION: An EAT of ≤30 dBHL obtained by ABR and ASSR tests before 3 months of age is predictive of a normal hearing at 3 years of age in children born with cCMV.

Proteolysis of milk fat globule membrane proteins in preterm milk: a transient phenomenon with a possible biological role?

Milk fat globule membrane (MFGM) proteins constitute a milk fraction currently of great interest, as they appear to significantly contribute to milk protective role. We investigated these proteins in human preterm colostrum and milk. For the former we found a peculiar 2-DE pattern, with a spot concentration at low molecular weight, which mass spectrometry analysis showed to be fragments belonging to some MFGM proteins with a well-known biological and especially immunological role: lactadherin, membrane-associated lactoferrin, butyrophilin, clusterin and heavy-chain immunoglobulin. Since we were able to rule out protease activity after specimen collection, we hypothesize the localization of the proteolytic enzymes in the alveolar cell membranes of the mammary gland. This mechanism is probably under hormonal control and the unexpected advent of preterm delivery would not allow hormonal conditions typical of lactation to occur immediately, causing a delay in enzymatic inhibition. This hypothesis is supported by some of our results, picturing a peculiar transient phenomenon of adaptation of the mammary-gland-membrane proteins after preterm delivery. Further studies will be required to verify whether the presence of protein fragments exerts a specific biological and immuno-defensive role in preterm infants, thus adding evidence to the outstanding biological role and benefits of mother's own milk in feeding preterm infants.

Effects of Holder pasteurization on human milk oligosaccharides.

The benefits of human milk have been confirmed for preterm infants, due to its nutritional aspects and to its biologically active compounds. Oligosaccharides play an emerging leading role among these compounds. Mother's milk can sometimes be lacking for preterm infants; pasteurized donor milk represents therefore an important alternative. The aim of this study is to evaluate the effects of Holder pasteurization on the concentration and pattern of oligosaccharides in preterm human milk. Our results indicate that pasteurization does not affect the concentration or pattern of analyzed oligosaccharides.

Evaluation of postnatal growth in very low birth weight infants: a neonatologist's dilemma.

Very low birth weight (VLBW) infants' survival has greatly increased in the last few decades thanks to the improvement in obstetrical and neonatal care. The correct evaluation of postnatal growth of these babies is nowadays of primary concern, although the definitions of their optimal nutrition and postnatal growth pattern are still controversial. It is known that VLBW infants have a specific postnatal growth pattern markedly different from that of higher birthweight full-term infants. Prospective longitudinal studies are needed to trace VLBW infants growth charts for weight, length and head circumference. These charts will be a useful tool to monitor postnatal growth of VLBW infants both during hospitalisation and after discharge, up to 2 or 3 years of age. A useful tool in VLBW infants growth evaluation could also be absolute velocity charts that, allowing a better and earlier identification of growth anomalies, could permit the observation of phenomena not yet visible on distance charts. Very low birth weight (VLBW) infants' survival has greatly increased in the last few decades thanks to the improvement in obstetrical and neonatal care. These neonates represent about 1-1.5% of all live born infants in developed countries (1) and they constitute the large majority of the population in neonatal intensive care units (NICUs). For this reason, the correct evaluation of their postnatal growth is of primary concern nowadays although the definitions of optimal nutrition and postnatal growth pattern are still controversial.

Cardiorespiratory events in infants with gastroesophageal reflux symptoms: Is there any association?

BACKGROUND: Cardiorespiratory (CR) events (apnea, bradycardia, oxygen desaturation) and gastroesophageal reflux (GER) symptoms often coexist in infants admitted to Neonatal Intensive Care Unit, leading to over-prescription of drugs and delayed discharge. We aimed to evaluate the relationships between CR and GER events. METHODS: The temporal associations between CR and GER events were analyzed in symptomatic infants who underwent synchronized CR and pH-impedance monitoring. The symptom association probability (SAP) index was used to identify infants with a significant number of temporal associations. Gastroesophageal reflux characteristics and the chronological sequence of CR and GER events occurring within 30 seconds of each other were evaluated according to SAP index. KEY RESULTS: Of the 66 infants enrolled, aged 29 (18-45) days, 58 had CR events during monitoring. From these 58 patients, a total of 1331 CR events and 5239 GER (24% acidic) were detected. The SAP index was positive in seven (12%) infants. These infants had greater GER frequency, duration, and proximal extent (P < .05). The number of temporal associations was 10 times greater in the positive SAP group. Gastroesophageal reflux events preceded CR events in 83% of these associations. These GER events had a higher proximal extent (P = .004), but showed no differences in pH values. CONCLUSIONS & INFERENCES: The simultaneous evaluation of CR and GER events could be useful to identify infants with severe GER and significant temporal associations between these events. Treatment of GER could be indicated in these infants, but as the GER events involved are mainly non-acidic, empirical treatment with antacids is, often, inappropriate.

Immunoglobulin-A profile in breast milk from mothers delivering full term and preterm infants.

Recent advances in the care of low-birth-weight and preterm neonates have stimulated research into the best dietetic program to improve their survival and short/long term outcome. Some components of human milk that cannot be included in artificial formulas may be critical for survival. Of these, immunoglobulins are important, and in particular secretory immunoglobulins A (sIgA). The concentration of secretory IgA was measured by immunoblotting (an immunoelectrophoretic technique having high specificity and reliability) in milk from mothers delivering at term (TM) or prematurely (PM). In both groups, IgA concentrations were high very early on but quickly decreased during the first week of lactation. The early IgA mean concentration was higher in PM than in TM but, because of high variability in PM milk, the difference rarely reached statistical significance. This variability during lactation reflects the important role of human milk in supplying immunological factors to cope with the gastrointestinal absorption of high molecular weight proteins in the first days of life. Immunological protection is particularly critical for a preterm baby, so it is important to promote feeding with its own mothers milk if possible, paying strict attention to the timing of milk collection.

Postnatal weight increase and growth velocity of very low birthweight infants.

BACKGROUND: Only a few studies have dealt with postnatal growth velocity of very low birthweight (VLBW) infants. OBJECTIVE: To analyse weight growth kinetics of VLBW infants from birth to over 2 years of age. PATIENTS: A total of 262 VLBW infants were selected; inaccurate estimate of gestational age, major congenital anomalies, necrotising enterocolitis, death, and loss to follow up within the first year were the exclusion criteria. METHODS: Body weight was recorded daily up to 28 days or up to discontinuation of parenteral nutrition, weekly up to discharge, then at 1, 3, 6, 9, 12, 18, and 24 months of corrected age. Individual growth profiles were fitted with a seven constant, exponential-logistic function suitable for modelling weight loss and weight recovery, two peaks, and the subsequent slow decrease in growth velocity. RESULTS: After a postnatal weight loss, all infants showed a late neonatal peak of growth velocity between the 7th and 21st weeks; most also experienced an early neonatal peak between the 2nd and 6th week. VLBW infants who were small for gestational age and those with major morbidities grew less than reference VLBW infants who were the appropriate size for gestational age without major morbidities: at 2 years of age, the difference in weight was about 860 g. The more severe growth impairment seen in VLBW infants with major morbidities is almost entirely due to the reduced height of the late neonatal peak of velocity. CONCLUSIONS: The growth model presented here should be a useful tool for evaluating to what extent different pathological conditions or nutritional and medical care protocols affect growth kinetics.

Detection of specific IgE to human milk proteins in sera of atopic infants.

Specific IgE (sIgE) for cow's milk proteins (CMP) have been reported to be present in blood sera of exclusively breast-fed infants. The aim of this study was to find whether the presence of sIgE to human milk proteins in the sera of exclusively breast-fed infants could explain the apparent detection of sIgE to CMP in infants that were never previously in contact with cow's milk. sIgE for human milk whey proteins were found in the blood sera of atopic infants, and these sIgE strongly cross-reacted with the corresponding CMP. In none of the sera examined were sIgE to bovine beta-lactoglobulin detected.

Identification of the human beta-casein C-terminal fragments that specifically bind to purified antibodies to bovine beta-lactoglobulin.

The presence of foreign proteins in human milk after the ingestion of bovine dairy products is thought to be one of the possible causes of allergic sensitization in exclusively breast-fed predisposed infants. The immunologic determination of bovine beta-lactoglobulin (LG) concentration in human milk has been reported by several researchers, but the results are conflicting. Moreover, a strong cross-reactivity between antibodies to bovine beta-LG and human milk proteins and peptides was reported, throwing doubt on the reliability of radioimmunoassay and enzyme-linked immunosorbent assay detection and quantification assays for bovine beta-LG in human milk. Thus, the goal of this study was to isolate human milk peptides with a molecular mass >or= 1,000 Da cross-reactive with antibodies to bovine beta-LG in order to identify possible common epitopes between human and bovine milk proteins. The proteins were first isolated by affinity chromatography with purified polyclonal antibodies to bovine beta-LG, followed by gel filtration fast phase liquid chromatography and reverse phase-high performance liquid chromatography purification of the components specifically bound in the affinity separation step. Affinity-bound peptides were identified by determining their amino acid sequence. All the sequenced peptides belonged to the C-terminal part of human beta-casein, which confirms the cross-reactivity of human milk proteins and peptides with antibodies to bovine beta-LG and allows the identification of possible common epitopes between the two proteins. No bovine beta-LG peptides with a molecular mass >or= 1,000 Da were found in our milk samples from healthy mothers on a diet rich in bovine milk and dairy products.

Detection of cow's milk proteins and minor components in human milk using proteomics techniques.

Cow's milk proteins (CMPs) are the best characterized food allergens. The aim of this study was to investigate cow's milk allergens in human colostrum of term and preterm newborns' mothers, and other minor protein components by proteomics techniques, more sensitive than other techniques used in the past. Sixty-two term and 11 preterm colostrum samples were collected, subjected to a treatment able to increase the concentration of the most diluted proteins and simultaneously to reduce the concentration of the proteins present at high concentration (Proteominer Treatment), and subsequently subjected to the steps of proteomic techniques. The most relevant finding in this study was the detection of the intact bovine alpha-S1-casein in human colostrum, then bovine alpha-1-casein could be considered the cow's milk allergen that is readily secreted in human milk and could be a cause of sensitization to cow's milk in exclusively breastfed predisposed infants. Another interesting result was the detection, at very low concentrations, of proteins previously not described in human milk (galectin-7, the different isoforms of the 14-3-3 protein and the serum amyloid P-component), probably involved in the regulation of the normal cell growth, in the pro-apoptotic function and in the regulation of tissue homeostasis. Further investigations are needed to understand if these families of proteins have specific biological activity in human milk.