PROTECTIVE GUT & NUTRITION

STRATEGIES

Scientific data prepared byDr. Ragia Labieb

Presented by:Perwin Aly Waly

Neonatology residentN.I.C.U _ Ain Shams University

June 2009

Important questions

_ Parenteral or enteral feeding ????

_ Meaning of aggressive nutrition ????

_ The optimal nutritional goals ????

_ TPN ( quality and quantity ) ????

_ Minimal Enteral Feeding ( MEN ) ???

_ Breast feeding or Artificial feeding ???

_ Summary and conclusion ?????

• Our clinical approach to provide nutritional support that impact neonatal morbidity and long-term neurodevelopmental outcomes by by what's called aggressive nutrition .

Aggressive Nutrition

• These include early administration of intravenous amino acids , lipids and minimal enteral nutrition (by human milk or supplemented formulas ) with full-strength rather than dilute formula or sterile water .

Potential Benefits of Early Aggressive Nutrition

• The most critical developmental period of brain growth and function occurs during the last trimester of pregnancy and the first 2 years of postnatal life.

• So malnutrition in this period may have long-term developmental consequences

WHAT IS MSG???

.

• Aggressive nutrition is initiating (TPN) in the first hours after birth and administering it in conjunction with initially small, and then advancing, enteral feedings beginning on the first or second day of life.

Advantages of Aggressive Nutrition

• The use of TPN is a mean to achieve rapid, maximal nutrition

• And early enteral feedings are designed to prime the gut and stimulate normal hormonal homeostasis(

The Optimal Nutritional Goal for Preterm Neonates

• AAP recommended that The current standard for postnatal nutrition in PT is to duplicate the normal inutero fetal growth rates.

• But for ELBW infants, postnatal duplication of normal in utero growth rates may not be a realistic goal for medical, practical, and theoretical reasons, especially for the first several weeks of life.

• From the medical and practical standpoints, the weight changes in an ELBW infant during the first 1 to 2 weeks of life reflects more fluid management than tissue deposition.

• Fluid administration generally is targeted to cover IWL.

• But also relative fluid restriction usually is practiced to prevent development of PDA, with some neonatologists advocating allowing weight to decrease as much as 15% to 20% below BW in the 1st days of life.

Total Parenteral Nutrition ( TPN )

QUALITY&QUANTITY

Protein Mass • the body compartments that can change

significantly with nutrition are protein mass and fat mass.

• Unfortunately, measurements of body composition cannot be obtained easily for clinical purposes.

• Increase in protein mass is a measure of true growth, However : good estimates of protein accretion can be made in most infants based on nutritional protein intake

Fat mass

• Fetal fat accretion occurs primarily by transplacental transport of lipid, and in the human infant this does not occur in significant amounts until the third trimester

• So the rate of increase in fat mass in the PT and ELBW infant are a more complex and controversial issue.

Neonates are very efficient at using a.a for protein accretion.

• If there are no superimposed catabolic influences, protein gain increases linearly with protein intakes

Amino Acids

• Studies revealed that in utero 26wks fetus is receiving proteins transplacentally with an approximately 4gms/kg .

• So why will we cut down this amount????????????

• Early introduction of amino acids .

• an elevated urea concentration may reflect acceptable production of an acceptable metabolic byproduct rather than protein intolerance .

Practical tips

Message

• We administer substrates aggressively from the first day of life, particularly protein, with a goal of providing fetal nutrient delivery rates to the neonate as soon as possible to avoid the period of early neonatal malnutrition.

PLS DON’T

• Nevertheless, it is common practice in many NICUs to provide intravenous glucose alone for several days and to limit protein administration to ELBW or sick neonates in the early neonatal period because of concerns that these fragile patients may not tolerate protein.

• Often this practice is based on data from adult studies in which a variety of stresses (surgical, traumatic, infectious) induce a catabolic response that is not ameliorated by protein administration.

WHHY NOT???WHHY NOT???

• In addition of preventing catabolism and promoting anabolism, early protein administration may have several other beneficial effects in 1st days of life.

• These include decrease the frequency and severity of neonatal hyperglycemia by stimulating endogenous insulin secretion and stimulating growth by enhancing the secretion of insulin and insulin-like growth factors.

MINIMAL ENTERAL NUTRITION ( MEN )

• Early initiation of MEN is advocated as a supplement to parenteral nutrition in the NICU population.

• Some studies suggest that physiologic benefits occur: at volumes as low as less than 1 mL/kg per day. "priming" feedings because of their role in stimulating many aspects of gut function

SAFETY

• In a prospective, randomized study in PT ( 680 to 1,440 gms )

• one group was given MEN starting in the first week of life & the other group received TPN only for the first 2 weeks of life.

Safety

• Contrary to the original hypothesis, the incidence of NEC was significantly lower in the MEN group.

• But their was a high incidence of NEC in those who received enteral feeding with a rapid increasing rates .

EFFICACY Although • volume of feedings• day of initiation of feedings• caloric density &rate of advancement are varied

• demonstrated the beneficial effects of MEN and no obvious detrimental effects.

AllAllstudiesstudies

These advantages of MEN included

• shorter time to full enteral feedings .• less time under phototherapy .• a lower incidence of direct hyperbilirubinemia .• smaller gastric residuals .• less feeding intolerance .• the same or faster weight gain .• and no increased incidence of NEC .

Slide 2h

Why do we prefer human milk

The intestine is the primary immune organ in the body because it contains 60% of the total immunoglobulins and more than 106 lymphocytes/gm tissue.

Role of the gut in immune Role of the gut in immune functionsfunctions

Kelly D Trends in immunology Kelly D Trends in immunology 20052005

Immature Conditions of the Neonate’s Immune System

Immune system is shifted towards the Th2 pathway to protect the foetus from the

mother’s system

Limited exposure of antigens in utero

Still no memory has been build up

AAntibodies alonentibodies alone serve to transmit the mother's serve to transmit the mother's immunologic experience to theimmunologic experience to the fetus and infant; fetus and infant; these, and not these, and not the fetal the fetal T cells, protect the childT cells, protect the child

while its own immune system matureswhile its own immune system matures

Zinkernagel RM NEJM 2001

Breast feeding or formulas

• Among 300 children undergoing (IQ) testing:

• Those who had received human milk in 1st

weeks of life had significantly higher scores than those who had consumed no maternal milk. (even when adjusted for maternal social and educational status(.

•Additionally, there was a dose-dependent correlation between quantity of human milk consumed and IQ score.

Why do we prefer human milk

• The neonatal adaptive immune system, relatively naive to foreign antigens, requires synergy with the innate immune system to protect the intestine .

• Breast-feeding reduces enteric infection and . may reduce chronic disease in later life and . Allergic diseases .

Benefits of breast feeding for the infant

• Provides superior nutrition for optimum growth.

• Provides adequate water for hydration.

• Protects against infection and allergies.

• Promotes bonding and development.

Slide 2.1

ColostrumProperty

• Antibody-rich

• Many white cells

• Purgative

• Growth factors

• Vitamin-A rich

Importance

• protects against infection and allergy

• helps in intestinal maturation

• clears meconium; helps in preventing jaundice

• prevents vitamin A-related eye diseases

Slide 2.5

• Human milk can be considered a symbiotic, a substance that has the properties of both a pro- and prebiotic.

• Human milk contains lipids and nucleotides which play major role in the gut immunity .

Commensal Probiotic

Fermentedmilk

Prebioticsupplementation

Probioticsupplementation

Enhance intestinal

epithelial barrier

Anti-inflammatory effects in intestinal

epithelial cells

Balanced Th1/Th2 response promoting

tolerance and reducing

inflamatory, auto-immune and allergic

diseaeses

Interrest of commensal probiotic stimulationInterrest of commensal probiotic stimulation

The lipids in human milk become antiviral,

antibacterial, and antiprotozoal in vivo after

digestion in the gastrointestinal tract. Microbial

killing by milk lipids is due primarily to FFAs and

monoglycerides released from milk triglycerides

( mainly oleic acid ) by both milk-derived bile-

salt– stimulated lipase and lipolytic activity in the

infant’s gut .

Das UN 2002 & Isaacs CE 2005

lipidslipids

The protective effect of breast feeding against atopy might be attributed to its high content in ω-6 . In addition, its modulatory influences on Th1 and Th2 responses.

The favorable action on Th1 and Th2 responses may depend on the ratio between ω-3 and ω-6 fatty acids. A higher ratio of ω-6 to ω-3 favors an enhancement in the Th1 response, whereas a decrease in the ratio between ω-6 to ω-3 may favor the Th2 response.

lipidslipids

Das UN 2002

nucleotidesnucleotides

Agget P 2003; Field CJ 2005; Yu V 2002; Carver JD 2003

Nucleotides affect the composition of intestinal microbiota in lactating infants

Modify the immune system (humoral response and immune cell development)

Reduce incidence of gastrointestinal infections

Increase postprandial superior mesenteric

blood flow velocity

SO Risks of artificial feeding

Interferes with bonding

More diarrhoea and respiratory infections

Malnutrition& Vitamin A deficiency

More allergy and More allergy and milk intolerance milk intolerance

Increased risk of some chronic diseases

Overweight

Lower scores on intelligence tests

May become pregnant sooner

Increased risk of anaemia, ovarian and breast cancer

Adapted from: Breastfeeding counseling: A training course. Geneva, World Health Organization, 1993 (WHO/CDR/93.6). Slide 2.26

• But what if the human milk (breast feeding ) is insufficient .

• Or there is no choice and we had to use formula .

• PT or FT formula ???????????????

• Some studies revealed that : -

PT Or FT Formula ???•

• "sole diet" infants followed up at 7.5 to 8 years of age: those who had received term formula had significantly lower verbal IQ scores than those who received preterm formula, and this difference was most pronounced in males.

• There was also a higher incidence of cerebral palsy in the term formula group.

Summary Summary & conclusion& conclusion

A newborn’s immune system needs special A newborn’s immune system needs special measures of protection and supportmeasures of protection and support

Breast milk strengthens an infant’s immune Breast milk strengthens an infant’s immune system, leading to less infections and system, leading to less infections and

allergiesallergies

Summary Summary & conclusion& conclusion

Sometimes it is a matter of life or death for babies ! As new study clearly points

out for the first time that timing of beginning breast feeding is

independently linked to survival of babies. This is the key point of the

presentation and discussion

5/2

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Beginning Breastfeeding within Beginning Breastfeeding within ONEONE .. hour : hour : ( Beginning life with “life”)( Beginning life with “life”)

Thank you