Wednesday, November 07, 2012
Vevey, Switzerland – 7th November 2012: At a Nestlé Nutrition Institute satellite symposium held at the European Academy of Paediatric Societies (EAPS), in Istanbul on 7 October 2012, leading experts brought into sharp focus the importance of prioritizing pre-term infants' nutrition for short and long-term health and development outcomes. Currently a gap exists between recommendations and actions in this evolving field and speakers reinforced the value of current treatment strategies as well as exploring further research needs.
Mimicking intra-uterine growth rates: the goal
Professor Hans van Goudoever, Head of Paediatrics, VU University Medical Center, Amsterdam outlined the framework within which nutritional strategies are deployed for pre-term infants: “Basically our goal is to mimic intrauterine growth rate and body composition, but most importantly to obtain a functional outcome comparable to infants born at term”. He also highlighted the scale of the issue. In Europe alone, 500,000 infants are born prematurely, so it is vital that these infants’ nutritional needs are addressed in order to influence the long-term health prognosis of the population at large.
He reinforced that human milk is regarded as the preferred feed for pre-term infants, reducing the incidence of necrotising enterocolitis (NEC) and improving neurocognitive development1,2. However, in these infants, nutrient requirements are very high, particularly for protein3. So human milk alone is not sufficient to meet these needs and consequently growth is sub-optimal when compared to intrauterine growth rates4.
The addition of human milk fortifiers has been shown to improve growth in the neonatal period, however there is also evidence that infants fed pre-term formula have higher rates of growth than infants fed with fortified human milk5,6. Reflecting the evolving and still inconclusive nature of this area of research, Professor Goudoever said, “It is clear that fortifiers have improved the nutritional status of pre-term infants. However, more powerful research is required to develop further these fortifiers to better mimic intrauterine growth and development”.
Evolving role of human milk banks
Professor Karen Simmer, Centre for Neonatal Research and Education, University of Western Australia, Perth described that the development of Human Milk Banks in Australia is motivated to a significant degree by the need to reduce the incidence of Necrotising Enterocolitis (NEC) and maintain or increase breast-feeding rates after preterm birth.
Over 90% of mothers give breast milk to their babies and it is known that this is beneficial for cognitive development, as well as being effective in reducing obesity and the risk of infection, including NEC. Many of these advantages may also be achieved by the use of Pasteurised Donor Human Milk (PDHM), which has been available for over a century and the results of studies to date indicate a marked effect on the reduction of NEC and improvement of neurocognitive development. Commenting on the practical challenges still facing the PDHM concept, Professor Simmer noted, “To set up a milk bank, legal and safety aspects have to be carefully considered. The questions that remain to be investigated in the future are about how to retain protein quality? What is the role of fresh donor milk? What would be the optimal supplementation of pasteurized donor human milk and how to reduce contamination and/or develop an alternate fast method of detecting contamination pre-pasteurisation”? She also noted that more data is required on the long-term benefits or otherwise of donor milk, particularly in regard to insulin resistance and body composition.
Premature birth – a nutritional emergency
Professor Thibault Senterre, MD, PhD, from the University of Liège, Belgium, described the importance of early nutritional intakes, considering premature birth as a ‘nutritional emergency’. He highlighted the consequences of the frequent practice of accumulating nutritional deficit in pre-term infants and the lack of consistent adherence to relevant recommendations and guidelines7 on nutrition support. In particular, he referred to one study that suggests that early intakes during the first week of life may influence long-term outcomes8, commenting, “I would like to describe insufficient intakes below what is recommended as malnutrition – if you decrease protein and/or energy intake you may decrease the IQ of the pre-term infant at eighteen months. This may be avoided in very low birth weight (VLBW) infants and therefore have a positive impact on severity of illnesses and neurocognitive functions”.
Professor Senterre reinforced that optimizing nutritional support is possible and valuable. He referred to positive results achieved in the Liège study started in 2005, based upon adherence to a protocol of enteral and parenteral nutrition in VLBW infants9: “Our data showed that only 6% of VLBW infants at gestational age had developed a post-natal growth restriction, which is very low when compared to other published studies. Moreover, improved post-natal growth seems to improve metabolic homeostasis. I really think we need to prioritize the improvement of nutritional support for the majority of VLBW infants”.
1. Sullivan S, Schanler RJ, Kim JH, Patel AL, Trawoger R, Kiechl-Kohlendorfer U, et al. An exclusively human milk-based diet is associated with a lower rate of necrotizing enterocolitis than a diet of human milk and bovine milk-based products. The Journal of pediatrics. 2010; 156(4): 562-7 e1.
2. Isaacs EB, Fischl BR, Quinn BT, Chong WK, Gadian DG, Lucas A. Impact of breast milk on intelligence quotient, brain size, and white matter development. Pediatric research. 2010; 67(4): 357-62.
3. Agostoni C, Buonocore G, Carnielli VP, De Curtis M, Darmaun D, Decsi T, et al. Enteral nutrient supply for preterm infants: commentary from the European Society of Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition. Journal of pediatric gastroenterology and nutrition. 2010; 50(1): 85-91.
4. Ehrenkranz RA, Younes N, Lemons JA, Fanaroff AA, Donovan EF, Wright LL, et al. Longitudinal growth of hospitalized very low birth weight infants. Pediatrics. 1999; 104(2 Pt 1): 280-9.
5. Kuschel CA, Harding JE. Multicomponent fortified human milk for promoting growth in preterm infants. Cochrane Database Syst Rev. 2004; (1): CD000343.
6. Schanler RJ, Shulman RJ, Lau C. Feeding strategies for premature infants: beneficial outcomes of feeding fortified human milk versus preterm formula. Pediatrics. 1999; 103(6 Pt 1): 1150-7.
7. Practical Approach to Paediatric Enteral Nutrition: ESPGHAN 2010
8. Stephens BE, Walden RV, Gargus RA, et al. First-week protein and energy intakes are associated with 18-month developmental outcomes in extremely low birth weight infants. Pediatrics. 2009 May; 123(5): 1337-43.
9. Senterre T, Rigo J. Optimizing early nutritional support based on recent recommendations in VLBW infants and postnatal growth restriction. Senterre T 2011, 2012: J Pediatric Gastroenterol Nutr.2011 Nov;53(5):536-42.
Notes to editors:
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