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Department of Pediatrics, Division of Neonatology, VU University Medical Center, 1081 HV, Amsterdam, The Netherlands
* To whom correspondence should be addressed. E-mail: hn.lafeber{at}vumc.nl.
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ABSTRACT |
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Introduction |
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TOPABSTRACTIntroductionLITERATURE CITED |
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Infections in preterm infants may originate in utero (6). In particular, intraamniotic bacterial infections in relation to premature rupture of membranes may cause preterm birth followed by a severe threat of immediate postnatal sepsis and/or meningitis. Another cause of infections of which the origin can be found in severe IUGR caused by poor placental function during the second and last trimester of fetal development may be traced to intrauterine infections. In the Western world, this is often caused by severe preeclampsia, leading to a poor perfusion via the placenta and resulting in a relative sparing of the brain but a very poor development of the splanchnic organs including the gut. The underdeveloped gut, often suffering from relative hypoxia, is very sensitive to poor motility, leading to stasis in the lumen and rapid overgrowth of (potentially) pathogenic bacteria (7). This may lead to the typical disease seen in high-risk preterm infants: necrotizing enterocolitis (NEC) (7). That these risk factors causing infections in preterm infants often originate before birth should always be considered in investigating the effects of pre- and/or probiotics added to the nutrition of these infants. The hostile environment in the lumen of the gut of preterm infants may be caused by pathogenic factors before birth, and the growth of pathogenic bacteria during the early postnatal period may be enhanced by relative hypoxia from poor ventilation.
Origin of infections related to the NICU environment
Recently, we reviewed the literature on the development of the intestinal microflora of preterm infants and the factors influencing its environment (8). Most studies show that the intestinal bacterial colonization with beneficial bacteria is delayed in preterm infants (8).
The number of potentially pathogenic bacteria is high. The widespread use of antibiotics at the NICU has a negative effect on the development of the intestinal microflora. Many preterm infants receive prophylactic antibiotics at birth. Over the period 1998–2000, a surveillance study on nosocomial infections was performed at our NICU (9,10). During 50% of the admission time, at least 1 antibiotic was administered to the preterm infants (9). The risk of sepsis was negatively related to birth weight: <1000 g birth weight, 31% risk of sepsis; 1000–1500 g birth weight, 28% risk of sepsis; and 1550–2500 g birth weight, 4% risk of sepsis. Apart from low birth weight, another high-risk factor for sepsis in preterm infants is the use of total parenteral nutrition mixtures (9,10).
Origin of infections related to the gastrointestinal tract
Severe infections in preterm infants often originate from the gastrointestinal (GI) tract because of the developmental immaturity of the gut. Often the gut wall is not yet fully mature, and the ultimately tight junctions between the mucosal cell layers are still open, permitting bacteria from the intestinal lumen to penetrate into the interstitium or vascular system causing sepsis (11). The process of gut maturation is influenced not only by the gestational age but also by the effect of administrating enteral feeding late or early by so-called gavage feeding using an indwelling plastic probe. Over the last 10–15 y, the concept of minimal enteral trophic feeding has been introduced into clinical practice: the early start of enteral feeding in small quantities (maximal 12–24 mL · kg–1 · d–1) in ventilated preterm infants during the period of parenteral feeding to enhance the gut function and with the intention to enable full enteral feeding sooner after birth (12). Preferably breast milk is given by nasal drip into the stomach to enhance mucosal development because mucosal growth factors in human milk facilitate mucosal growth (13). Pulsed minimal enteral feeding with breast milk may stimulate gastric emptying and may cause less reflux than bolus feeding. There may also be several nonmucosal effects of minimal enteral feeding such as stimulation of the motor activity of the muscular layer of the gut and enhancement of the postprandial response: lowering of the vascular resistance of the gut wall and increased oxygen consumption (14). Breast milk consumption may also result in the release of endocrine and metabolic factors such as gastrin, enteroglucagon, motilin, neurotensin, gastroinhibiting peptide, and pancreatic polypeptide (15). Enhancement of Lactobacillus and Bifidus flora by breast milk, known to diminish the risk of overgrowth of (potentially) pathogenic bacteria has already been discussed above. All these factors may lower the risk of NEC, a clinical entity in preterm infants leading to extremely high morbidity and/or mortality (7,16,17).
It remains very difficult, however, to collect sufficient clinical evidence for the validity of the concept of minimal enteral feeding (18). Most relevant clinical studies have been reviewed in a Cochrane meta-analysis (12,16). We concluded that minimal enteral feeding diminishes the number of days to reach full enteral feeding without increasing the risk of NEC. A study by Mihatsch et al. (19) showed that, even in IUGR preterm infants, the first postnatal day that full enteral feeding can be administered is reached earlier by increasing the amount of nutrition by 16 mL · kg–1 · d–1 up to 160–176 mL · kg–1 · d–1 until enteral nutrition is reached. Following this protocol, no increase in the incidence of NEC was observed, and the infants left the NICU sooner. In contrast, Berseth et al. (20) in 2003 claimed that increasing the amount of enteral nutrition with 20 mL · kg–1 · d–1 in preterm infants could be responsible for the fact that the team observed more cases of NEC.
Effects on infections by components of the nutrition
Quantitative aspects of important metabolic nutritional substrates: proteins. Proteins/amino acids are important anabolic substrates for the developing fetus and newborn. From numerous kinetic metabolic studies in preterm infants using amino acids labeled with stable isotopes, we know that the daily protein gain in preterm infants may be as high as 2 g · kg–1 · d–1 of protein during preterm life (21). This can be reached only by feeding fortified human milk or special protein-enriched preterm formula.
As demonstrated by Embleton et al. (22), preterm infants, particularly those born below 30 wk gestational age, may suffer from an increasing cumulative energy/protein deficit despite all efforts to feed them properly. The catabolic situation that develops in such infants has a negative effect on their infection risk during their time of stay in the NICU.
Qualitative aspects of important metabolic substrates: essential amino acids. Apart from protein quantity, the protein quality of the enteral feeding may influence metabolic conditions in the luminal part of the developing gut. Essential amino acids such as glutamine and glutamate are important energy sources for the intestinal intraepithelial lymphocytes, which require these amino acids for their proliferation (23). Indirectly, these amino acids may contribute to important functions including production of secretory immunoglobulin preservation of the gut-associated lymphoid tissue system and intestinal integrity (maturation of the crypt cells), prevention of bacterial translocation, and decrease of transcellular permeability (23–26). In a randomized controlled trial, Van den Berg et al. (27,28) investigated the effects of glutamine supplementation on the enteral feeding of 102 very low-birth-weight newborn infants. As clinical outcomes, feeding tolerance, serious infectious morbidity, and short-term outcome were investigated together with the postnatal adaptation of the gut and possible modulation of the immune response. No direct effects of enteral glutamine supplementation were seen studying the development of the intestinal microflora at postnatal day 30 (Table 2).
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Breast milk contains numerous factors with direct trophic effects on the intestinal wall cell layer protecting the infant to infections, resulting in better absorption and motility (13). In this manner it may help to protect a preterm infant to the pathophysiological process of NEC (13). This protection may be caused by an inhibiting effect on the development of a potentially pathogenic intestinal microflora that results from stimulating the growth of Bifidobacteriae and Lactobacillus strains (29,30).
Effects of nucleotides
Nucleotides are components of human milk that have been identified as affecting the immune function. In animal models, nucleotides have been shown to stimulate growth and maturation of the GI tract (31). Over the past 10 y, several clinical studies have shown effects of infant formula containing nucleotides on the immune status of infants (5,32). Most studies describe stimulated humoral responses after vaccination (5) and effects on the immune cell development (33). It is interesting to note that in both term and preterm infants, dietary nucleotides stimulate the intestinal circulation directly as observed by measuring the blood flow in the superior mesenteric artery (34,35). However, the clinical implications of these findings remain to be determined.
Effects of probiotics
Feeding with breast milk leads to the development of a healthy intestinal microflora of Lactobacillus and Bifidobacteriae instead of the potentially pathogenic Enterobacteriae. In an attempt to create a similar effect, clinical studies have been conducted to investigate the addition of Lactobacillus and/or Bifidus bacteria directly to the formula of infants (2,36,37). In term infants, positive effects have been described on the development of Lactobacillus and Bifidus in the gut microflora (36,37). In particular, infants with diarrhea may restore their gut function more rapidly and dramatically after addition of probiotics to the formula (36). For preterm infants, it is feared that probiotics may contribute to the onset of bacterial resistance against antibiotics, whereas most Bifidus and Lactobacillus strains may be killed by the use of broad-spectrum intravenously administered antibiotics (38). Only Lin et al. (39) in Taiwan investigated the effects of the addition of probiotics in preterm infants. This study reported no side effects and showed beneficial effects on survival, infection rate, and incidence of NEC in preterm infants. However, it was surprising to see that the incidence of NEC was much higher in Taiwan than in either North America or Europe (39).
Effects of prebiotics
The immunomodulatory effects of oligosaccharides in infant nutrition have been described frequently (40–43). Most studies describe a bifidogenic effect on the gut microflora and a positive effect on the incidence of infections at short term and possibly also at long term. The bifidogenic effect may also lead to less atopy (4). Characteristically, softer stools are also observed after introduction of galacto-oligosaccharides or mixtures of galacto- and fructo-oligosaccharides (1,2). Similar clinical beneficial effects have been described in a limited number of studies in preterm infants (3,44). One of the problems in preterm infants is the widespread use of broad-spectrum antibiotics, negatively influencing the bifidogenic development of the gut microflora (3). To study the long-term effects of adding prebiotics to infant formulas, more clinical studies are needed (45). At present, we are investigating the (possibly) beneficial effects of adding so-called acidic (46) and neutral oligosaccharides to the formula in preterm infants.
In summary, we conclude that studying the immunomodulatory effects of breast milk and dietary components such as pre- and probiotics and nucleotides added to the preterm formula in preterm infants is complex because of the multicausal risk of infections in these infants. A multitude of immunoregulatory factors, then, must be considered in clinical studies investigating the effects of immune components in the nutrition of preterm infants.
Other articles in this supplement include references (48–57).
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FOOTNOTES |
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2 Author disclosures: H. N. Lafeber, E. A. M. Westerbeek, A. van den Berg, W. P. F. Fetter, and R. M. van Elburg, no conflicts of interest.
3 Abbreviations used: GI, gastrointestinal; IUGR, intrauterine growth retardation; NEC, necrotizing enterocolitis; NICU, neonatal intensive care unit.
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LITERATURE CITED |
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TOPABSTRACTIntroductionLITERATURE CITED |
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1. Moro G, Minoli L, Mosca M, Fanaro S, Jelinek J, Stahl B, Boehm G. Dosage-related bifidogenic effects of galacto- and fructo oligosaccharides in formula-fed term infants. J Pediatr Gastroenterol Nutr. 2002;34:291–5.[CrossRef][Medline]
2. Bakker-Zierikzee A. Prebiotics and probiotics in infant formulae [dissertation]. Wageningen, The Netherlands: Wageningen University; 2005.
3. Boehm G, Lidestri M, Casetta P, Jelinek J, Negretti F, Stahl B, Marini A. Supplementation of a bovine milk formula with an oligosaccharide mixture increases counts of faecal bifidobacteria in preterm infants. Arch Dis Child Fetal Neonatol Ed. 2002;86:F178–F181.
4. Moro G, Arslanoglu S, Stahl B, Jelinek J, Boehm G. Effect of a prebiotic mixture of galactooligosaccharides and long chain fructooligosaccharides on the cumulative incidence of atopic dermatitis in infants at risk. Arch Dis Child. 2006;91:814–9.
5. Schaller JP, Kuchan MJ, Thomas DL, Cordle CT, Winship TR, Buck RH, Baggs GE, Wheeler JG. Effect of dietary ribonucleotides on infant immune status. Part 1: Humoral responses. Pediatr Res. 2004;56:883–90.[CrossRef][Medline]
6. Schrag S, Schuchat A. Prevention of neonatal sepsis. Clin Perinatol. 2005;32:601–15.[Medline]
7. Bell MJ, Rudinsky M, Brotherton T, Schroeder K, Boxerman SB. Gastrointestinal microecology in the critically ill neonate. J Pediatr Surg. 1984;19:745–51.[CrossRef][Medline]
8. Westerbeek EAM, Van den Berg A, Lafeber HN, Knol J, Fetter WPF, Van Elburg RM. The intestinal bacterial colonisation in preterm infants: A review of the literature. Clin Nutr. 2006;25:361–8.[CrossRef][Medline]
9. Van der Zwet WC. Epidemiology and prevention of nosocomal infection in the neonatal intensive care unit [dissertation]. Amsterdam: Vrije Universiteit; 2007.
10. Van der Zwet WC, Kaiser AM, Van Elburg RM, Berkhof J, Fetter WPF, Parlevliet GA, Vandenbroucke-Grauls CMJE. Nosocomial infections in a Dutch neonatal intensive care unit: surveillance study with definitions for infection specifically adapted for neonates. J Hosp Infect. 2005;61:300–11.[CrossRef][Medline]
11. Caicedo RA, Schanler RJ, LI N, Neu J. The developmental intestinal ecosystem: implications for the infant. Pediatr Res. 2005;58:625–8.[CrossRef][Medline]
12. Tyson JE, Kennedy KA. Trophic feeding for parenterally fed infants. Cochrane Database Syst Rev. 2005;3:CD000504.[Medline]
13. McGuire W, Anthony MY. Donor human milk versus formula for preventing necrotising enterocolitis in preterm infants: systematic review. Arch Dis Child Fetal Neonatal Ed. 2003;88:F11–4.
14. Adlerberth I. Establishment of a normal intestinal microflora in the newborn. In: Hanson LA, Yolken RH, editors. Probiotics, other nutritional factors and intestinal microflora, vol 42. Nestlé Nutrition Workshop Series. Basel: Karger; 1999. p. 63–78.
15. Dai D, Walker WA. Protective nutrients and bacterial colonization in the immature human gut. Adv Pediatr. 1999;46:353–82.[Medline]
16. Premji S, Chessell L. Continuous nasogastric milk feeding versus intermittent bolus milk feeding for premature infants less than 1500 grams. Cochrane Database Syst Rev. 2003;1:CD001819.[Medline]
17. Duffy LC, Zielezny MA, Carrion V, Griffiths E, Dryja D, Hilty M, Cummings J, Morin F. Bacterial toxins and enteral feeding of premature infants at risk for necrotizing enterocolitis. Adv Exp Med Biol. 2001;501:519–27.[Medline]
18. Lafeber HN. Are there beneficial effects of rapid introduction of enteral feeding in VLBW infants, even in those with severe IUGR? J Pediatr Gastroenterol Nutr. 2002;35:137–8.[CrossRef][Medline]
19. Mihatsch WA, Pohlandt F, Franz AF, Flock F. Early feeding advancement in very low birthweight infants with intrauterine growth retardation and increased umbilical artery resistance. J Pediatr Gastroenterol Nutr. 2002;35:144–8.[CrossRef][Medline]
20. Berseth CL, Bisquera JA, Paje VU. Prolonging small feeding volumes early in life decreases the incidence of necrotizing enterocolitis in VLBW infants. Pediatrics. 2003;111:529–34.
21. Micheli JL, Schutz Y. Protein. In: Tsang RC, editor. Nutritional needs of the preterm infant. Baltimore: Williams & Wilkins; 1993. p. 29–46.
22. Embleton NE, Pang N, Cooke RJ. Postnatal malnutrition and growth retardation: an inevitable consequence of current recommendations in preterm infants? Pediatrics. 2001;107:270–3.
23. Neu J. Glutamine supplements in premature infants: why and how. J Pediatr Gastroenterol Nutr. 2003;37:533–5.[CrossRef][Medline]
24. Windmueller HG. Glutamine utilization by the small intestine. Adv Enzymol Relat Areas Mol Biol. 1982;53:201–37.[Medline]
25. Newsholme EA, Crabtree B, Ardawi MS. Glutamine metabolism in lymphocytes: its biochemical, physiological and clinical importance. Q J Exp Physiol. 1985;70:473–89.
26. Tubman TR, Thompson SW, McGuire W. Glutamine supplementation to prevent morbidity and mortality in preterm infants. Cochrane Database Syst Rev. 2005;1:CD001457.[Medline]
27. Van den Berg A, van Elburg RM, Westerbeek EA, Twisk JWR, Fetter WPF. Glutamine enriched enteral nutrition in VLBW infants and effects on feeding tolerance and infectious morbidity: a randomized controlled trial. Am J Clin Nutr. 2005;81:1397–404.
28. Van den Berg A, van Elburg RM, Teerlink T, Lafeber HN, Twisk JWR, Fetter WPF. A randomized controlled trial of enteral glutamine supplementation in VLBW infants: plasma amino acid concentrations. J Pediatr Gastroenterol Nutr. 2005;41:66–71.[CrossRef][Medline]
29. Hoy C, Millar MR, Mackay P, Godwin PG, Langdale V, Levenne MI. Quantitative changes in faecal microflora preceding necrotising enterocolitis in premature neonates. Arch Dis Child. 1990;65:1057–9.
30. Harmsen HJ, Wildeboer-Veloo AC, Raangs G, Wagendorp A, Klijn N, Bindels JG. Analysis of intestinal flora development in breast-fed and formula-fed infants by using molecular identification and detection methods. J Pediatr Gastroenterol Nutr. 2000;30:61–7.[CrossRef][Medline]
31. Uauy R, Stringel G, Thomas R, Ouan R. Effect of dietary nucleoside on growth and maturation of the developing gut in the rat. J Pediatr Gastroenterol Nutr. 1990;10:497–503.[Medline]
32. Pickering LK, Granoff DM, Reed Erickson J, Masor ML, Cordle CT, Schaller JP, Winship TR, Paule CL, Hilty MD. Modulation of the immune system by human milk and infant formula containing nucleotides. Pediatrics. 1998;101:242–9.
33. Buck RH, Thomas DL, Winship TR, Cordle CT, Kuchan MJ, Baggs GE, Schaller JP, Wheeler JG. Effect of dietary ribonucleotides on infant immune status. Part 2: Immune cell development. Pediatr Res. 2004;56:891–900.[CrossRef][Medline]
34. Carver JD, Saste M, Sosa R, Zaritt J, Kuchan M, Barness LA. The effects of dietary nucleotides on intestinal blood flow in preterm infants. Pediatr Res. 2002;52:425–9.[CrossRef][Medline]
35. Carver JD, Sosa R, Saste M, Kuchan M. Dietary nucleotides and intestinal bloodflow velocity in term infants. J Pediatr Gastroenterol Nutr. 2004;39:38–42.[Medline]
36. Neu J, Caicedo RA. Probiotics: protecting the intestinal ecosystem? J Pediatr. 2005;147:143–6.[CrossRef][Medline]
37. van der Waaij D. Microbial ecology of the intestinal microflora: influence of interactions with the host organism. In: Hanson LA, Yolken RH, editors. Probiotics, other nutritional factors and intestinal microflora. Nestlé Nutrition Workshop Series, vol 42. Basel: Karger; 1999. p. 1–15.
38. Millar M, Wilks M, Costeloe K. Probiotics for preterm infants. Arch Dis Child Fetal Neonatal Ed. 2003;88:F354–8.
39. Lin HC, Su BH, Chen AC, Lin TW, Tsai CH, Yeh TF, Oh W. Oral probiotics reduce the incidence and severity of necrotizing enterocolitis in VLBW infants. Pediatrics. 2005;115:1–4.
40. Schmelzle H, Wirth S, Skopnik H, Radke M, Knol J, Böckler HM, Brönstrup A, Wells J, Fusch C. Randomized double-blind study of the nutritional efficacy and bifidogenicity of a new infant formula containing partially hydrolyzed protein, a high β-palmitic acid level, and nondigestible oligosaccharides. J Pediatr Gastroenterol Nutr. 2003;36:343–51.[CrossRef][Medline]
41. Knol J, Scholtens P, Kafka C, Steenbakkers J, Gross S, Helm K, Klarczyk M, Schopfer H, Böckler HM, Wells J. Colon microflora in infants fed formula with galacto- and fructo-oligosaccharides: more like breast-fed infants. J Pediatr Gastroenterol Nutr. 2005;40:36–42.[CrossRef][Medline]
42. Rinne MM, Gueimonde M, Kalliomaki M, Hoppu U, Salminen SJ, Isolauri E. Similar bifidogenic effects of prebiotic-supplemented partially hydrolyzed infant formula and breastfeeding on infant gut microbiota. FEMS Immunol Med Microbiol. 2005;43:59–65.[CrossRef][Medline]
43. Euler AR, Mitchell DK, Kline R, Pickering LK. Prebiotic effect of fructo-oligosaccharide supplemented term infant formula at two concentrations compared with unsupplemented formula and human milk. J Pediatr Gastroenterol Nutr. 2005;40:157–64.[CrossRef][Medline]
44. Mihatsch WA, Hoegel J, Pohlandt F. Prebiotic oligosaccharides reduce stool viscosity and accelerate gastrointestinal transport in preterm infants. Acta Paediatr. 2006;95:843–8.[Medline]
45. Agostoni C, Axelsson I, Goulet O, Koletzko B, Michaelsen KF, Puntis JWL, Rigo J, Shamir R, Szajewska H, Turck D. Prebiotic oligosaccharides in dietetic products for infants: a commentary by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr. 2004;39:465–73.[CrossRef][Medline]
46. Fanaro S, Jelinek J, Stahl B, Boehm G, Kock R, Vigi V. Acidic oligosaccharides from pectin hydrolysate as new component for infant formulae: effect on intestinal flora, stool characteristics and pH. J Pediatr Gastroenterol Nutr. 2005;41:186–90.[CrossRef][Medline]
47. Van den Berg A. Glutamine-enriched enteral nutrition in very low birth weight infants [dissertation]. Amsterdam: Vrije Universiteit; 2007.
48. Visser HKA. Dietary influences on infection and allergy in infants: Introduction. J Nutr. 2008;138:1768S–9S.
49. Wahn HU. Strategies for atopy prevention. J Nutr. 2008;138:1770S–2S.
50. Szépfalusi Z. The maturation of the fetal and neonatal immune system. J Nutr. 2008;138:1773S–81S.
51. M'Rabet L, Vos AP, Boehm G, Garssen J. Breast-feeding and its role in early development of the immune system in infants: consequences for health later in life. J Nutr. 2008;138:1782S–90S.
52. Morelli L. Postnatal development of interstinal microflora as influenced by infant nutrition. J Nutr. 2008;138:1791S–5S.
53. Biasucci G, Benenati B, Morelli L, Bessi E, Boehm G. Cesarean delivery may affect the early biodiversity of intestinal bacteria. J Nutr. 2008;138:1796S–800S.
54. Chirico G, Marzollo R, Cortinovis S, Fonte C, Gasparoni A,. Antiinfective properties of human milk. J Nutr. 2008;138:1801S–6S.
55. Gottrand F. Long-chain polyunsaturated fatty acids influence the immune system of infants. J Nutr. 2008;138:1807S–12S.
56. Boehm G, Moro, G. Structural and functional aspects of prebiotics used in infant nutrition. J Nutr. 2008;138:1818S–28S.
57. van Goudoever J, Corpeleijn W, Riedijk M, Schaart M, Renes I, van der Schoor S. The impact of enteral IGF-1 and nutrition on gut permeability and amino acid utilization. J Nutr. 2008;138:1829S–33S.
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