Postdischarge nutrition,

Transcription

1 Postdischarge nutrition, is there a role for human milk? Harrie N. Lafeber MD,Ph.D. Professor of Neonatology, VU university medical center, Amsterdam, NL

2 Ehrencranz et al.

3 Indirect calorimetry

4 kcal /kg /day

5 In-hospital growth velocity and neurodevelopment (n=600; g) (Ehrenkranz, R.A. Pediatrics 2006;117: ) 40 MDI < 70 (P<0.01) 40 PDI < 70 (P<0.001) % 20 % Weight gain quartiles (g/(kg. d)) Weight gain quartiles (g/(kg. d)) % Cerebral palsy (P<0.01) % Neurodevelopmental impairment (P<0.001) Weight gain quartiles (g/(kg. d)) Weight gain quartiles (g/(kg. d))

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7 Postnatal growth failure in ELBW infants Courtesy of Prof. Dr. E.E. Ziegler

8 Embleton NE, Pang N, Cooke RJ Pediatrics 107: Energy Intake (kcal/kg/w) Cumulative Energy Deficit (kcal/kg) (19) (16) (12) (8) (43) (30) (26) (20) (16) (11) * * - 30 weeks - 31 weeks * - p < w Postnatal Age

9 Embleton NE, Pang N, Cooke RJ Pediatrics 107: Protein Intake (kcal/kg/w) Cumulative Protein Deficit (kcal/kg) 25 * * (w) Postnatal Age - 30 weeks - 31 weeks * - p <.001

10 From: Senterre & Rigo, Acta Paediatrica 2011

11 From: Senterre & Rigo, Acta Paediatrica 2011

12 de Boo HA, Cranendonk A, Kulik W, Harding JE, Lafeber HN. J Pediatr Gastroenterol Nutr. 2005;41:81-7 Nutritional intakes in preterm infants Fortified Human Milk Nenatal Volume (ml) 152 ( ) 152 ( ) Energy (Kcal) 118 ( ) 121 ( ) Protein (g) 2.9 ( ) 3.6 ( )* Carbohydrates (g) 13.7 ( ) 11.8 ( ) * Fat (g) 6.1 ( ) 6.7 ( ) Data are median (range) per kg/d * P 0.05, Mann-Whitney test

13 Protein kinetics from valine HM PF 7 g/kg/d * Turnover Synthesis Breakdown Accretion * p 0.05, Mann-Whitney test

14 Protein kinetics from phenylalanine HM PF g/kg/d * 2 1 Turnover Synthesis Breakdown Accretion * p 0.05, Mann-Whitney test

15 de Boo HA, Cranendonk A, Kulik W, Harding JE, Lafeber HN. J Pediatr Gastroenterol Nutr. 2005;41:81-7 Conclusions from clinical study in preterm infants Formula fed preterm infants showed higher protein accretion than fortified human milk fed preterm infants Conclusion: Estimated protein content of human milk combined with standard prescription of human milk fortifier is often too low! Increase the protein content of human milk fortifier for preterm infants or add special protein fortifier to human milk.

16 From Michaeli et al. 1995

17 What are the options for post discharge nutrition? Human milk (HM) HM + Fortifier Term formula (TF) Post discharge Formula (PDF) Preterm formula (PTF) Energy (kcal/dl) Protein g/dl 1,0 1,7-2,1 1,4-2,0 1,8-1,9 2,4-2,6 Lipids g/dl 3,4 3,4-4,5 2,7-4,1 3,5-4,4 3,2-5 Carbohydrates g/dl 7 7,2-10,6 7,9 7,

18 Nutrient-enriched discharge formula for preterm infants (Henderson G et al. Cochrane Database Syst Rev 2007) Carver Cooke De Curtis Koo Litmanovitz Lucas Lucas A N 67 vs vs vs vs vs vs vs. 116 <1800g <1750g <1750g <35SSW <1500g <1850g <37SSW <37SSW <37SSW <3000g Kcal 74 vs vs vs vs vs vs vs. 68 D/C-12mo D/C-6mo D/C-2mo D/C-12w D/C-6mo wks D/C-9mo Weight (m) - (m) Length (m) - (SGA) HC (<1250g) (m) - ( ) (SGA) -- Neurodevelopment SEX effekt No data ( )(m) No data No data (SGA) Ns. +0.9/+2.8 M M No No data M M

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20 Study Towards the Effects of Postdischarge Nutrition Prematuren geboren bij 32 weken zwangerschapsduur en/of 1500 gram geboortegewicht

21 Standard formula and postdischarge formula have equal caloric content 80 kcal/100ml 67 kcal/100ml Preterm formula 2,8 g prot./100kcal Postdischarge formula 2,6 g prot./100kcal Preterm formula 2,8 g prot./100kcal Term formula 2,2 g prot./100kcal Discharge 6 months CA

22 STEP studie Amesz EM, Schaafsma A, Cranendonk A, Lafeber HN. Optimal growth and lower fat mass in preterm infants fed a protein-enriched postdischarge formula. J Pediatr Gastroenterol Nutr. 2010;50: Type of formula Friso prematuur Friso prematuur1 [postdischarge] Friso standard formula Energy, kcal Protein, g Protein/Energy ratio, g/100 kcal 2.8/ / /100 Carbohydrates,, g Fat, g 4,3 3,5 3,5

23 STEP studie Special preterm formula fed n=102 Fortified human breastmilk n= randomized at 40 w. postconc. age 53 postdischarge formula (PDF) 49 term formula (TF) 50 human milk (HM) 0 m. 52 PDF 48 TF 26 human milk HM 3 m. Dexa- scans T=0 48 scans T=0 35 scans T=0 27 scans T=6 44 scans T=6 34 scans T=6 20 scans 6 m.

24 DEXA scan % Fat mass Lean body mass Bone density

25 Protein intake of all infants before discharge Amesz et al 2010

26 Results STEP 1 study formula fed infants Weight Length No differences between isocaloric/protein enriched postdischarge formula and standard formula Amesz et al. JPGN 2010; 50:

27 Bodycomposition expressed as % of weight

28 Conclusions No differences in weight, length and head circumference were seen between infants fed protein-enriched enriched but not energy enriched formula or standard formula after term corrected age (40 weeks postconceptional age).

29 Conclusions Infants fed standard formula have a larger fat mass percentage at 6 m. c.a., as compared to infants fed protein-enriched postdischarge formula. Infants fed standard formula have a lower lean mass percentage at 6 m, as compared to infants fed protein-enriched postdischarge formula.

30 Picaud et al. 2008

31 Picaud et al. 2008

32 Postdischarge nutrition, is there a role for human milk?

33 Growth of all preterm infants Weight No significant differences

34 Gain in bone content / density 0-6 months Delta DEXA 0 and 6 months PDF TF HM p N Delta BMC / delta G dexa in % (BMC gain) 2,27 ± 0,30*# 2,16 ± 0,26 1,99 ± 0,32 0,010 Delta BMD / delta G dexa in % (BMD gain) 0,090 ± 0,022* 0,077 ± 0,018 0,061 ± 0,029 0,000 * PDF vs HM p <0,05 PDF vs TF P < 0,05 # PDF vs HM p <0,1

35 Conclusion from human milk study Despite similar body size, infants fed (fortified) human milk after discharge gain less bone mass and have a significantly lower bone mineral density at 6 months corrected age, compared to infants fed postdischarge formula

36 Amesz et al. JPGN 2010; 50: Differences in bodycomposition between postdischarge formula, standard formula and human milk at 6 months corrected age p 1 PDF versus TF; p 2 PDF versus HM Conclusion: Postdischarge formula Friso Prematuur 1 Larger gain lean mass at 6 m. corrected age Smaller gain fat mass at 6m. corrected age

37 Results of iron status in STEP1 Iron status parameters at 0, 3 and 6 months corrected age: Hemoglobin, hematocrit, MCV, MCH, MCHC, red cell distribution width, reticulocytes Serum iron, transferrin, ferritin, transferrin saturation Parameters indicating iron deficiency and anaemia: Hemoglobin, hematocrit, RDW Ferritin (if CRP < 5 mg/l)

38 Results Iron deficiency and anaemia (%) at 0, 3 and 6 months corrected age in preterm infants fed formula or human milk (HM) 0 months Formula vs HM 3 months Formula vs HM 6 months Formula vs HM Hb < 5.9 mmol/l 43.5 versus versus versus 2.2 Ht < 0.32 l/l 82.6 versus versus 28.3** 4.3 versus 6.5 Ferritine < 10 µg/l 3.3 versus versus 15.2* 3.3 versus 17.4** RDW > 14.5% 9.8 versus 26.1** 8.7 versus 28.3** * p<0.05 ** p<0.005

39 Results Mean MCV, RDW and ferritin at 6 months in preterm infants fed formula or human milk 6 months Formula versus human milk MCV (fl) 77.7 ± 3.3 versus 75.2 ± 5.4** RDW (%) 12.7 ± 1.3 versus 14 ± 2.6** Ferritin (µg/l) 35 ± 82.4 versus 16.6 ± 7.5* * p<0.05 ** p<0.005

40 Conclusions Very low birth weight preterm infants fed human milk and given external supplemental iron at 1-2 mg/kg/d only until 0-3 months corrected age more frequently show signs of iron deficiency at 3 and 6 months corrected age compared to formula fed infants. Very low birth weight preterm infants fed iron fortified formula and given external supplemental iron at 1-2 mg/kg/d until 0-3 months corrected age more frequently show signs of high iron deposition at 3 and 6 months corrected age

41 Advice regarding iron supplementation Breastmilk Oral iron supplementation (1-2 mg/kg/day) until 6 months corrected age Formula feeding No oral ironsupplementation needed, unless low ferritine levels Remember: iron supplementation is only needed when iron is deficient as shown by low ferritine and not shown by a low Haemoglobin level!

42 Vitamine D supplementation Independent of formula or breastfeeding, skincolour or time of the year for first 4 years of life

43 Studies in progress: STEP 2 Study at 7 years focusing on: Body composition Markers of metabolic syndrome Insulin insensitivity Blood pressure Cardiac performance Neurodevelopment