At a Nestlé Nutrition Institute Satellite Symposium held at the European Academy of Paediatric Societies (EAPS) held in Copenhagen, Denmark, leading experts made the case to change clinical practice in pre- and early post-natal nutrition to improve neonatal growth and protection.
Improving long term health of preterm infants
PROFESSOR HANS VAN GOUDOEVER: Professor Goudoever drew attention to research showing that addressing early nutritional deficits amongst Low Birth Weight Infants can have a positive impact on neurological development.
In Europe alone, every year 500,000 infants are now born pre-term. Widespread availability of recent neonatal innovations means that an increasing number of infants born at an early gestation age are surviving1, 2.
Professor Hans van Goudoever, VU University Medical Centre, Department of Paediatrics, Amsterdam and Emma Children’s Hospital, Amsterdam, explained the need for change in clinical practice to address early nutritional deficits amongst pre-term infants as a route to support body and organ growth, especially the brain. New clinical practice offers the opportunity to reduce the occurrence of long-term health issues – IQ restrictions, delays in neurodevelopmental outcomes, cardiovascular diseases, and many others.
Professor van Goudoever explained that pre-term newborns are vulnerable to slipping into poor nutritional status, as current practice is too slow to introduce enteral nutrition, probably due to physicians’ concern of intolerance. The foetus in utero (with nutrients provided via the umbilicus) is continuously supplied with high amounts of amino acids and glucose and would experience rapid brain growth. Commenting upon the importance of an adequate intake of protein and amino acids for prevention of growth faltering in early life, Professor van Goudoever said, “Our goal must be to mimic intra-uterine growth and body composition and to obtain a functional outcome comparable to infants born at term.”
In addition, Professor van Goudoever drew attention to research showing that addressing early nutritional deficits amongst Low Birth Weight Infants (LBWI) can have a positive impact on their neurological development. Research has shown that after adjusting for variables, a 10 kcal/kg per day increase in energy intake during the first week of life was associated with a 4.6 point increase in Mental Development Index (MDI) at 18 months corrected age. Even more striking, an increase of 1gr/kg per day of protein was associated with a 8..2 point increase in MDI3.
To ensure clinical practice moves in the right direction in this developing area of neonatal care, Professor van Goudoever strongly supported the new 2010 ESPGHAN guidelines for Enteral Nutrition of LWB Infants4. These include a much higher intake of protein (3.5-4.5g/kg/d) than used previously. He shared the various research that underpinned this shift, including evidence that the gut utilises a considerable amount of protein (50% on average), which is not available systematically5. Also, only 20% of specific amino acids are reaching systemic circulation6. Given these issues, Professor van Goudoever justified higher amino-acid intake of 4- 4.5 g/kg/d with preterm formulas and highlighted the importance of not tapering off parenteral amino acids before at least 75 ml/kg/d human milk/formula is provided enterally.
Food allergy Prevention in Preterm & Term Neonates
The Symposium also focused on the still emergent issue of food allergy prevention in neonates, both term and pre-term. Dr. Anne Des Roches, Service d’Immunologie Clinique et Allergie, Département de Pédiatrie CHU Sainte-Justine, Université de Montréal, Canada, explained that food allergy is a hypersensitivity reaction, mostly IgE-mediated, that occurs in reaction to various food proteins.
DR ANNE DES ROCHES: Dr. Roches focused on the issue of food allergy prevention in neonates.
Articulating the scale and significance of food allergy, Dr. Des Roches shared estimates that the prevalence of food allergy peaks at 6-8 % at one year of age and then falls progressively until late childhood. Milk allergy will affect nearly 2% of the paediatric population7 and 15% of these milk allergic children will not loose their allergy in later life8. The persistence of their allergy is associated with a clear impact on quality of life for both the children and their families.
Dr. Des Roches focused on the difficulties of diagnosing milk allergy amongst neonates and in particular preterm ones. Based upon an evaluation of a birth cohort in Norway, the symptoms of milk allergy in neonates are often more subtle than those for other allergic reaction; pain and crying (48%) was the dominant symptom9.
Studies to date have shown neonates' risk factors to allergy are related to maternal asthma or maternal food allergy, rather than pre-term or low birth weights. Dr. Des Roches commented, “Preventive diet during pregnancy and breastfeeding is still a matter of debate. The lack of valid studies on that topic means there is no consensus on the value of preventive diet. The official authorities in allergy do not recommend preventive diet during pregnancy and breastfeeding, however they do not disapprove of it either”.
Dr. Des Roches went on to say, “Milk avoidance during the first year of life has been associated with a significant decrease of milk allergy. Whilst this has been considered of minor interest in the past, the impact of this preventive measure is not without interest today. In my view the use of hypoallergenic mother milk fortifier with extensively hydrolysed protein for premature infants and hypoallergenic formula with proven preventive effect in neonates should be advocated in those children born to atopic families and so at greater risk of developing milk allergy”.
Immunonutrients via Enteral route for Premature Infants
PROFESSOR JOSEF NEU: Professor Neu discussed the role of immonutrients in developing intestinal innate immune system as a primary barrier protecting the internal from external environment.
Professor Josef Neu from the University of Florida Gainesville, USA shared the growing understanding of the role of immunonutrients in developing intestinal innate immune system as a primary barrier protecting the internal from external environment. Premature infants are a vulnerable population with high risk of intestinal damage, sepsis via the GI tract & necrotising enterocolitis (NEC) mainly due to barrier dysfunction. Enteral nutrients deprivation is known as one of the factors affecting barrier function.
The importance of enteral feeding administration vs. Total Parenteral Nutrition (TPN) as also discussed in relation to LWB infants for improving intestinal permeability, improving feeding tolerance and growth. Professor Neu explained that data is accumulating showing that the major factor responsible for TPN induced bacterial translocation is the lack of enteral feeding and not the administration of the TPN solution itself10. Recent studies support the introduction of minimal enteral nutrition without increase in complications such as NEC.
Professor Neu also proposed that essential amino acids such as arginine and glutamine might be beneficial. He went on to say, “Glutamine is taken up by the foetus more than any other amino acid and this is suddenly interrupted in premature birth. A study11 undertaken by my own group in Florida, based upon supplementation of glutamine via the enteral route in human milk or formula demonstrated a decrease in hospital acquired sepsis, a decreased cost of hospitalisation and increased tolerance to enteral feeding.”
Satellite Symposium Abstract (pdf, 2 Mb)
Notes to editors:
The Nestlé Nutrition Institute (NNI) fosters "Science for Better Nutrition" because we are convinced that innovative, science-based nutrition can help enhance the quality of people's lives all over the world. The role of the NNI is to:
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For more information, please consult the Nestlé Nutrition Institute website
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- Wood NS, Marlow N, Costeloe K, Gibson AT, Wilkinson AR. Neurologic and developmental disability after extremely preterm birth. EPICure Study Group. N Engl J Med. 2000 Aug 10;343(6):378-84.
- Group E, Fellman V, Hellstrom-Westas L, Norman M, Westgren M, Kallen K, et al. One-year survival of extremely preterm infants after active perinatal care in Sweden JAMA. 2009 Jun 3;301(21):2225-33.
- Stephens BE, Walden RV, Gargus RA, Tucker R, McKinley L, Mance M, 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.
- Enteral Nutrient Supply for Preterm Infants: Commentary from Committee on Nutrition of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN); JPGN Volume 50, Number 1, Jan. 2010
- Series of studies published in Gut AJCN., JNutr., Pediatr Res., 2004-2009
- Series of studies published in Gut AJCN., JNutr., Pediatr Res., 2004-2009
- Sampson HA, in Food Allergy: Adverse reactions to foods and food additives 2003
- Saarinen, J Allergy Clin Immunol 2005 Ford, Arch Dis Child 1982 Uriso, J Allergy Clin Immunol 1997 Skolnick HS, J Allergy Clin Immunol 2001 Ko MHK, J Allergy Clin Immunol 2008
- Kvenshagen B., Halvorsen R., Jacobsen M., Adverse reactions to milk in infants, Acta Pediatrica 2008, Volume 97, Issue 2, pages 196–200
- Barbara E. Wildhaber, et al. Lack of enteral nutrition effects on the intestinal immune system J Surg. Res. 2005
- Neu J, Roig JC, Meetze WH et al. – Enteral glutamine supplementation for very low birth weight infants decreases morbidity. J Pediatr 1997;131:691-699.