fortify placer 14 ho - placer lactation conferences · mat = maternal milk ptf = pre-term formula...

For$fying Human Milk May 2014

R. S. Cohen, MD 1

RONALD S. COHEN, MD

M E D I C A L D I R E C T O R - P I C N L U C I L E S . P A C K A R D C H I L D R E N ’ S H O S P I T A L

C L I N I C A L P R O F E S S O R O F P E D I A T R I C S S T A N F O R D U N I V E R S I T Y S C H O O L O F M E D I C I N E

M E D I C A L D I R E C T O R M O T H E R S ’ M I L K B A N K O F S A N J O S É

Feeding Premature Infants: Why, When, & What

To Add To Human Milk

2014

1

R. S. Cohen, MD

Goals of Talk

2014 R. S. Cohen, MD

2

1.  Identify common nutritional concerns for premature babies

a.  While they are in the NICU, and b.  After they’ve gone home from the NICU.

2.  Can we tell when these needs are not being met? a.  Can human milk be used to meet these needs, and b.  Can adding to human milk help meet these needs?

3.  Review evidenced-based discharge feeding practice for prematurely born infants.

Unique Abbreviations

  BDM = Banked Donor Milk   MAT = Maternal Milk   PTF = Pre-Term Formula   PDF = Post-Discharge Formula   HMBANA = Human Milk Banking Association of North America   HMF = Human Milk Fortifier   H2MF = Human-milk derived HMF   NEC = Necrotizing Entero-Colitis   LPF = Liquid Protein Fortifier

2014

3

R. S. Cohen, MD

What is “Banked Donor Milk”?


4

  Mother’s health screened   By their own MD/OB   Same health questionnaire used by Blood Bank   Serologic testing except for CMV

  Medication use tightly restricted   No tobacco or non-prescription drug use allowed

  Milk thawed & cultured prior to processing   Milk Holder Pasteurized & re-cultured   Milk pooled prior to re-freezing & distribution

Does Holder Pasteurization Work?


5

  “Holder pasteurization was, however, an effective means by which to remove any detectable bacteria from samples of donor human milk.”1

  “22 bottles (Table) had been thawed for 7 to 122 hours (mean 46.7 ± 28.4). None of the samples had any bacterial growth, including 18 bottles thawed and refrigerated appropriately for more than 24 hours.”2

  No infections linked to HMBANA BDM in >30 years.

1. Landers S, Updegrove K. Breastfeed Med 2010; 5:117-21. 2. Cohen RS, et al. Breastfeed Med 2012; 7:282-4 .

BDM & CMV

  Heat treatment destroys CMV1:   Holder Pasteurization @ 62.5° C;   “Flash” Pasteurization @ 72° C.

  Freeze/thaw may not eliminate CMV:   Freezing for 1 year, then freeze/thaw x 3 did NOT eliminate

infectious virus1;   5 of 36 CMV positive mothers transmitted CMV to 6 babies despite

freezing2;   2 of 23 CMV positive mothers transmitted CMV to 2 babies despite

freezing & Cesaerean delivery3.

1. Hamprecht K, et al. Pediatr Res 2004; 56:529-35. 2. Jim W-T, et al. Pediatr Infect Dis J 2004; 23:848-51. 3. Lee HC, et al. Pediatr Infect Dis J 2007; 26:276.

2014

6

R. S. Cohen, MD


R. S. Cohen, MD 2

HMBANA & HIV


7

  “Donor human milk banks that belong to the Human Milk Banking Association of North America (http://www.hmbana.org/) voluntarily follow guidelines of the Centers for Disease Control and Prevention (CDC), which include screening of donors for infectious transmissible agents as well as heat treatment of the milk.”

  “Holder pasteurization (ie, heating at 62.5°C for >30 minutes) is the only method that completely eradicates HIV in all human milk components and is the current standard”

Committee on Pediatric Aids. Pediatrics 2013; 131:391–6. DOI: 10.1542/peds.2012-3543

World Association of Perinatal Medicine: Consensus

Arslanoglu S, Ziegler EE, Moro GE, at al.

J Perinat Med 2010; 38:347-51.

8


•  When mother’s milk is not available, fortified donor human milk is the recommended alternative for this group of infants.

“Breastfeeding and the Use of Human Milk”

Policy Statement

AAP Section on Breastfeeding

Pediatrics 2012; 129:e827–e841

doi:10.1542/peds.2011-3552

9


• Pasteurized donor human milk, appropriately fortified, should be used if mother’s own milk is unavailable or its use is contraindicated.

“Extra-Uterine Growth Restriction”

Ehrenkranz RA, et al.

Pediatrics 1999; 104:280-9.

10


“Extra Uterine Growth Restriction”


11

  Caloric deficits.   Protein deficits.   Calcium-Phosphorus deficits.

NICU Growth vs Outcome Short-term


Pediatrics 2006;117:1253-61.

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Short-term outcome


R. S. Cohen, MD 3

NICU Growth vs Outcome Long-term


Pediatrics 2006;117;1253-61.

13


Impact of increased early protein intake


14

1 g/kg daily Protein added = increase 8.2-point MDI!

Stephens BE, at al. Pediatrics 2009;123:1337–1343.

BUN to Monitor IV Protein Intake?

Ridout E, et al.

J Perinatol 2005; 25:130-3.

15


“In a group of infants with birthweight less than 1250 g who were receiving exclusive parenteral nutrition over the first days of life, no correlation was found between amino-acid intake and serum BUN concentration. Given the data supporting the importance of early amino-acid administration in premature infants, limiting amino acid intake based on serum BUN concentrations is not warranted.”

Oral Protein Intake & Weight Gain


16

  4.6 vs 3.8 g/kg daily protein intake.   Caloric intake not different.   Volume ~ 160 mL/kg daily.

  High protein resulted in better gain.   Average 23.1 ± 7 vs 16.7 ± 6 g/kg daily.   Effect greater in males than females.

  Nitrogen absorption ~ 80%.

16

Cooke R, et al. Pediatr Res 2006; 59:265-70.

HMF vs HMF + Protein ~1 g/dL


17

Biasini A, et al. J Matern Fetal Neonatal Med 2012; 25(Suppl 4):S72-4.

Oral Protein Intake & BUN

Cooke R, et al.

Pediatr Res 2006; 59:265-70.

18


- 17

BUN mg/dL


R. S. Cohen, MD 4

Oral Protein Intake & Base Excess

Cooke R, et al.

Pediatr Res 2006; 59:265-70.

19


Sequential analysis of human milk


20

Nommsen LA, et al. Am J Clin Nutr 1991; 53:457-65.

The “DARLING” Study

Approximately 1.2 g/dL Protein

Analysis of Donor Milk

Wojcik KY, et al.

J Am Diet Assoc 2009; 109:137-40.

21


About 1.1 g/dL

Prolacta claims 0.9 g/dL in their milk

Analysis of Preterm vs Term Milk


22

Bauer J, Gerss J. Clin Nutr 2011; 30:215-20.

Variability of Human Milk: Fortification


23

De Halleux V, Rigo J. Am J Clin Nutr 2013;98(suppl):529S–35S.

Comparison of Protein Analysis


24

De Halleux V, Rigo J. Am J Clin Nutr 2013;98(suppl):529S–35S.


R. S. Cohen, MD 5

Milk from NICU Mothers


25

Stellwagen L, et al. Breastfeed Med 2013; 8:205-9.

MMB San José Donor Milk - Then


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Protein Lactose Calories 1.24 g/dL 7.23 g/dL 20.5 kcal/oz

± 16% ± 6.7% ± 10%

Rivera A. Personal Communication.

MMB San José BDM Analysis – Now


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Protein Fat Lactose Calories 0.87 g/dL 3.34 g/dL 7.42 g/dL 19.90 kcal/oz

+/- 0.09 +/- 1.02 +/- 0.60 +/- 2.78

Rivera A. Personal Communication.

N = 73; January 2012

New Algorithm!!

Can Milk Provide Enough Protein?


28

Milk Protein Content (g/dL)

Fluid Intake (mL/kg daily)

Protein Intake (g/kg daily)

1.2 150 1.8 1.2 180 2.16 1.2 200 2.4 1.5 150 2.25 1.5 180 2.7 1.5 200 3

Fortification – Protein vs Osmolality?


29

Corvaglia L, et al. Early Hum Dev 2010; 86:237-40.

Measured vs Predicted Milk Content

Arslanoglu S, et al.

J Perinatol 2009; 29:489-92.

30



R. S. Cohen, MD 6

Variation in Milk Fat Content During A Feed

Khan S, et al.

J Hum Lact 2013; 29:81-9.

31


Milk Composition and Breastfeeding Pattern Over a 24-Hour Period


32

Khan S, et al. J Hum Lact 2013; 29:81-9.

Adjusted Fortification?


33

  Adjust fortification per BUN:   Protein powder added above standard HMF;   Decrease if > 14 mg/dL;   Increase if < 9 mg/dL.

  No difference in serum Albumin or Creatinine:   Clinically insignificant increase in BUN (~ 2 mg/dL).

  No NEC:   No formula feedings;   Diet ~ 60% Maternal & 40% BDM.

Arslanoglu S, et al. J Perinatol 2006; 26:614-21.

Growth with Fortified Human Milk


34


  Calories & Protein levels not as expected.   Most units cannot analyze milk in timely way.   Calories varied from pumping to pumping.   Analysis dependent upon good mixing.   Analysis varies from lab to lab.   Thus, vary fortification based upon growth and

metabolic status!

Analyze Human Milk?


35

“Treat the baby, not the bottle!”


Optimum Early Nutrition in NICU?


36

1.  Parenteral Protein – a.  Initiate right away, and b.  Advance to ≥ 3 – 4 g/kg daily.

2.  Initiate Enteral Nutrition immediately 3.  Push for “idealized” weight gain early –

a.  ≥ 15 g daily, or b.  ≥ 10% body weight weekly.

4.  Maximize Milk intake ≥ 180-200 mL/kg daily. 5.  Fortify with non-allergenic protein early –

a.  Increase if weight gain falters, or b.  Unable to maintain normal serum Albumin.


R. S. Cohen, MD 7

Recommendations for Adequate Nutrition


37

“(1) early, aggressive parenteral nutrition; (2) early enteral nutrition; (3) feeding of human milk with appropriate

fortification, especially in VLBW infants; and (4) feeding of premature infant formula when human

milk feeding is not possible.”

Bhatia J, et al. J Pediatr 2013; 162:S31-6.

NICU Standard Feeding Orders


38

  Parental Assent:   Parents informed of benefits & risks of BDM & formula.   Document assent before using BDM, H2MF or formula.   Similar assent needed for blood transfusion (CA law).

  Feeding Orders:   “Colostrum up to 0.5 mL q 6 h buccal when available.”   “Maternal milk xx mL q 3 h ….”   “When not available may use banked donor milk.”

Early Feeding Protocol


39

McCallie KR, et al. J Perinatol 2011; 31:S61-7.

Early Feeding Protocol


40

McCallie KR, et al. J Perinatol 2011; 31:S61-7.

Transition off H2MF at ~34 wk PMA: Maternal Milk Supply Adequate


41

LABS: albumin, BUN, alkaline phosphatase, calcium, phosphorus

Low risk VLBW Medium risk VLBW High risk VLBW

Routine feeders & growers; or

Wt gain adequate; or Labs WNL

SGA; or Wt gain inadequate; or

Labs mildly ABNL

Fluid restricted; or EUGR (Wt < 10th %); or

Wt gain poor; or Labs very ABNL

Unfortified MAT up to 180-200+ mL/kg/d

MAT plus LPF 1 g/kg/d (4 mL/100 mL)

180-200+ mL/kg/d

MAT:PTF30 2:1 ~23 kcal/oz 1:1 ~25 kcal/oz 1:2 ~27 kcal/oz

Transition off H2MF at ~34 wk PMA: Maternal Milk Supply Inadequate


42

Low risk VLBW Medium risk VLBW High risk VLBW

Routine feeders & growers;

Wt gain adequate; Labs WNL

SGA; Wt gain inadequate; Labs mildly ABNL

Fluid restricted; EUGR (Wt < 10th %);

Wt gain poor; Labs very ABNL

MAT:PTF30 2:1 (~23 kcal/oz)

or PDF 22 kcal/oz up to 180-200+ mL/kg/d

MAT:PTF30 1:1 (~25 kcal/oz)

or PDF 24 kcal/oz up to 180-200+ mL/kg/d

MAT:PTF30 1:1 ~25 kcal/oz 1:2 ~27 kcal/oz

or PTF 24 kcal/oz up to 180-200+ mL/kg/d



R. S. Cohen, MD 8

Early PO Protein & Sepsis??


43

Moltu SJ, et al. Clin Nutr 2013; 32:207-12.

Fortified formulas after discharge?


44

1.  “… on balance the evidence supports the use of fortified formulas in formula-fed preterm infants after hospital discharge.”

2.  “We are unaware of any evidence that any of the commonly proposed nutritional interventions in human milk–fed infants after hospital discharge are either safe or efficacious.”

3.  “… it seems prudent to avoid untested interventions in this population and to concentrate our efforts on the encouragement of breast-feeding after hospital discharge.”

Griffin IJ, Cooke RJ. J Pediatr Gastroenterol Nutr 2007; 45:S195-203.

Fortified Formula Post-Discharge


45

Roggero P, et al. Pediatrics 2012;130:e1215–e1221

Fortified Formula & Weight


46


Fortified Formula & Head Growth


47


Fortified Formula & Fat-free Mass


48



R. S. Cohen, MD 9

Fortify maternal milk after discharge?


49

1.  “No nutrition interventions have been proved in human milk-fed infants.”

2.  “Replacement of half to one third of the energy intake of human milk–fed infants with a PDF or a preterm formula leads to modest increases in nutrient intakes, and these replacements, although untested, could be offered to such infants who are under the 10th centile for weight at hospital discharge.”

3.  “The use of weaning foods enriched by energy, protein, iron, and zinc should be encouraged.”


Impact of Formula Fortified Human Milk


50


Fortification After Discharge for Growth?


51

Aimone A, et al. JPGN 2009; 49:456-66.

Fortification After Discharge for Bones?

Aimone A, et al.

JPGN 2009; 49:456-66.

52


Fortification After Discharge vs Lactation?


53


Fortification After Discharge for Development?


54

“No statistically significant differences were found between groups in the mental, motor,

or behavior rating scale scores of the Bayley II at 18-month CA.”



R. S. Cohen, MD 10

“Nutrient Enrichment of Mother’s Milk and Growth of Very Preterm Infants After Hospital Discharge.”


55

Zachariassen G, et al. Pediatrics 2011; 127:e995-e1003.

“Nutrient Enrichment of Mother’s Milk and Growth of Very Preterm Infants After Hospital Discharge.”


56

“WHAT THIS STUDY ADDS: Fortification of mother’s milk while breastfeeding her very preterm infant after hospital discharge is possible without influencing breastfeeding duration. The amount of fortification given in this study did not improve growth at 1 year of age compared with unfortified mother’s milk.”

Zachariassen G, et al. Pediatrics 2011; 127:e995-e1003.

Fortified Milk RE: Weight


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Young L, et al. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD004866. DOI: 10.1002/14651858.CD004866.pub4.

Fortified Milk RE: Head Size


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Fortified Milk Post-Discharge?


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  “The limited available data do not provide convincing evidence that feeding preterm infants with multinutrient fortified breast milk compared with unfortified breast milk following hospital discharge affects important outcomes including growth rates during infancy.”

  “There are no data on long-term growth.”   “Since fortifying breast milk for infants fed directly from

the breast is logistically difficult and has the potential to interfere with breast feeding, it is important to determine if mothers would support further trials of this intervention.”


Early Post-discharge Weight Gain Bad?


60

Euser AM, et al. Am J Clin Nutr 2005;81:480–7.

“Conclusions: In infants born very preterm, weight gain before 32 wk of gestation is positively associated with adult body size but not with body composition and fat distribution. More early postnatal and, to a lesser extent, late infancy weight gain are associated with higher BMI SD scores and percentage body fat and more abdominal fat at age 19 y.”


R. S. Cohen, MD 11

Catch-up Growth – Good, Bad, When?


61

Thureen PJ. J Pediatr Gastroenterol Nutr 2007; 45:S152-4.

“In humans, rapid rates of growth in childhood reportedly increase the risk for cardiovascular disease, hypertension, obesity, and type 2 diabetes later in life, but slower growth appears to be protective against later development of cardiovascular disease.”

Rapid Weight Gain in Infancy Bad?


62

Rotteveel J, et al. Pediatrics 2008;122;313-321.

“… the trajectory of growth of subjects that later develop glucose intolerance, hypertension, and coronary heart disease is often characterized by the crossing of SDS lines, normally still within the reference range.”

“Increments in height and weight during childhood contribute to the development of insulin resistance and high blood pressure in young adulthood.”

“Crossing Growth Percentiles in Infancy and Risk of Obesity in Childhood.”

Taveras EM, et al.

Arch Pediatr Adolesc Med 2011;165:993-8.

63


“Upward crossing of major weight-for-length percentiles in infancy, especially in the first 6 months of life, is associated with high rates of obesity at ages 5 and 10 years.”

Early Infant Weight Gain, Insulin Resistance, & Cardiovascular Risk Factors in Adolescence


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  “Early infant weight gain from birth to three months was positively associated with the fasting insulin concentration, HOMA-IR, basal lipid levels and systolic blood pressure at 17 years … in the SGA group.”

  “This study suggests that accelerated growth during the first three months of life may confer an increased risk of later metabolic disturbances – particularly of glucose metabolism – in individuals born SGA.”

Fabricius-Bjerre F, et al. PLoS ONE 2011; 6(6): e20595.

doi:10.1371/journal.pone.0020595

“Fetal and Infant Growth and Asthma Symptoms in Preschool Children. The Generation R Study.”


65

“Conclusions Weight gain acceleration in early infancy was associated with increased risks of asthma symptoms in preschool children, independent of fetal growth. Early infancy might be a critical period for the development of asthma.”

Sonnenschein-van der Voort AM, et al. Am J Respir Crit Care Med 2012;185:731-7. doi:10.1164/rccm.201107-1266OC

Rapid growth in Infancy?


66

  Increased risk of adult hypertension?   Increased risk of adult obesity?   Increased risk of diabetes?   New preliminary data – increased risk of asthma?

Maybe we shouldn’t push growth so hard?


R. S. Cohen, MD 12

“Reasons for Earlier Than Desired Cessation of Breastfeeding”


67

“RESULTS: Approximately 60% of mothers who stopped breastfeeding did so earlier than desired. Early termination was positively associated with mothers’ concerns regarding:

(1) difficulties with lactation; (2) infant nutrition and weight; (3) illness or need to take medicine; and (4) the effort associated with pumping milk.”

Odom EC, et al. Pediatrics 2013;131:e726–e732

Diet Regimens for NICU Grads


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Energy (Kcal/kg)

Ca (mg/kg)

Phos (mg/kg)

Protein (g/kg)

Milk + PDF powder added (22 kcal/oz)

131 62-64 32-34 2.2

Milk + PTF 24 2 Bottles/d

128 98-104 49-55 2.6-2.7

Milk + PDF 24 2 Bottles/d

128-129 76-82 41-43 2.4-2.5

Milk + PDF 22 2 Bottles/d

128 73-78 40-41 2.4

Assuming an intake of 180 mL/kg daily Per Olivia Mayer, RD - LPCH

VLBW Nutritional Support Post-Discharge: Maternal Milk Supply Adequate


69


Low Risk Medium Risk High Risk

Routine feeders & growers; or

Wt gain adequate; or Labs WNL

SGA; or Wt gain inadequate; or

Labs mildly ABNL

Fluid restricted; or EUGR (Wt < 10th %); or

Wt gain poor; or Labs very ABNL

Breast Feed ad lib Breast Feed ad lib & PDF22 2 feeds/d

(or Protein 1 g/kg/d?)

Breast Feed ad lib & PDF24 2-3 feeds/d

(or Protein 1 g/kg/d?)

VLBW Nutritional Support Post-Discharge: Maternal Milk Supply Inadequate


70

Low Risk Medium Risk High Risk

Routine feeders & growers;

Wt gain adequate; Labs WNL

SGA; Wt gain inadequate; Labs mildly ABNL

Fluid restricted; EUGR (Wt < 10th %);

Wt gain poor; Labs very ABNL

Breast Milk & PDF22

180-200+ mL/kg/d Breast Milk & PDF24 180-200+ mL/kg/d

Breast Milk & Hydrolyzed Formula24

180-200+ mL/kg/d




Pediatrics 1999; 104:280-9.

71




Pediatrics 1999; 104:280-9.

72


Old

Bad New Goal


R. S. Cohen, MD 13

It can be done!


73

Real growth chart from real 27-wk premie at LPCH, June 2011.

Timing of Nutritional Interventions


74

  “In VLBW preterm infants the most optimal nutritional intervention, which optimizes growth and brain development, is immediate postnatal high-protein nutrition.”

  “This can be obtained by innovative TPN and individualized fortified human breast milk to limit extrauterine growth restriction and to prevent the need for exaggerated post-term catch-up growth. This may reduce the risk of adverse metabolic consequences later in life.”

  For “… extrauterine growth restriction … in some VLBW infants, postdischarge nutrition given by a formula that is normal in energy but high in protein may result in a normal body composition and consequently may lower the risk of the development of metabolic syndrome later in life.”

Lafeber HN, et al. Am J Clin Nutr 2013;98(suppl):556S–60S.

Can We Prevent Bad Bones?


75

Harryhausen R. Jason and the Argonauts. 1963

Fetal Calcium & Phosphorus Accrual


76

  Last trimester   Ca 90 – 120 mg/kg daily   Phos 60 – 75 mg/kg daily

  Maternal supplements – minimal impact   Post-natal supplements do not provide enough

  Calcium absorption ~ 60 – 70%   Phosphorus absorption ~ 80 – 90

Sharp M. Early Hum Dev 2007; 83:653-8.

Current Recommended Oral Intakes


77

Demarini S. Acta Pædiatrica 2005; 94(Suppl 449):87-92.

AAP ESPGAN Ca (mg/100 Kcal) 140 – 160 70 - 140

Phos (mg/100 Kcal) 95 – 108 50 - 87

Ca:Phos Ratio ~ 1.5:1 1.4 – 1.6:1

Neonatal Calcium & Phosphorus Intake


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Land C, Schoenau E. Best Pract Res Clin Endocrinol Metab 2008; 22: 107-18.


R. S. Cohen, MD 14

Mineral Bioavailability: HMF vs Formula


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Rigo J, Santerre J. J Pediatr 2006;149:S80-S88. (doi: 10.1016/j.jpeds.2006.06.057)

Mineral Bioavailability: HMF vs Formula

Data:

Rigo J, Santerre J.

J Pediatr 2006; 149:S80-S88.

Figure:

Cohen RS, McCallie KR.

JPEN 2012; 36 (S1): S20-S24.

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Alkaline Phosphatase Levels?


81

  Wide fluctuations   Derived from Liver, Gut, and Bone   Increased by Bone healing, too   AlkPhos > 900 + low Phos may be significant   AlkPhos > 5x normal may be significant   AlkPhos > 1200 decreased length?

DeMarini S. Acta Paediatr 2005; 94(Suppl 449):87-92. Lucas A, et al. Arch Dis Child 1989; 64:902–9.

“Bone mineralisation in premature infants cannot be predicted from serum alkaline phosphatase or serum phosphate.”


82

Faerk J, et al. Arch Dis Child Fetal Neonatal Ed 2002;87:F133-6.

AAP Committee on Nutrition & Alkaline Phosphatase


83

  “Typically, the APA will peak at 400 to 800 IU/L and then decrease in VLBW infants who do not develop rickets.”

  “… clinical experience indicates that if the infant has APA values in this range and has achieved full feeds of human milk with a mineral-containing fortifier or formula designed for preterm infants, there is minimal, if any, risk of developing rickets, and measurement of APA can usually be stopped.”

Abrams SA, et al. Pediatrics 2013; 131:e1676–e1683.

Usefulness of Alkaline Phosphatase?


84

  “The in vivo effects of ALP remain under investigation and reflect the current evidence that it is not a useful indicator of disease when taken as a stand-alone marker.

  Independent measures of ALP are of little use in predicting and determining risk, or treatment thresholds, for MBD in preterm infants.

  ALP is not useful in monitoring on-going treatment for metabolic bone disease.

  High ALP levels in preterm infants are strongly associated with phosphorus deficiency and later growth, but do not predict outcome.

  ALP isoenzyme analysis is rarely helpful in determining causes of raised ALP.”

Tinnion RJ, Embleton ND. Arch Dis Child Educ Pract Ed 2012; 97:157–63.


R. S. Cohen, MD 15

“Diet and Bone Mineral Content at Term in Premature Infants”


85

Faerk J, et al. Pediatr Res 2000; 47:148–56.

No significant differences!

“Diet and Bone Mineral Content at Term in Premature Infants”


86

Faerk J, et al. Pediatr Res 2000; 47:148–56.

“Diet and Bone Mineral Content at Term in Premature Infants.”


87

 Calcium retention   70-80 mg/kg daily enterally for Premature infant,   Up to 140 mg/kg daily 3rd trimester in utero.

  “mineral supplementation in premature infants during admission does not significantly improve bone mineralization outcome at term if infants are fed 200 mL per kg per day.”

  “supplementation with phosphate is recommended only for prevention of hypophosphatemia.”

Faerk J, et al. Pediatr Res 2000; 47: 148–56.

Focus More on Phosphate?


88

  “Although most attention is focused on calcium intake, the very high urinary calcium concentrations found in preterm infants fed unfortified human milk suggests that phosphorus deficiency is at least as important, if not more important, than calcium deficiency in the etiology of this disease.”

  “The exact serum phosphorus concentration for which evidence demonstrates a need to supplement phosphorus without calcium is not known, but a serum concentration below ∼4.0 mg/dL, especially if present for more than 1 to 2 weeks, suggests consideration of adding phosphorus directly.”

Abrams SA, et al. Pediatrics 2013; 131:e1676–e1683.

Early Diet & Long-term Bone


89

Fewtrell MS, et al. Bone 2009; 45:142-9.

Results: Infant dietary randomization group did not influence peak bone mass or turnover. The proportion of human milk in the diet was significantly positively associated with WBBA and BMC. Subjects receiving >90% human milk had significantly higher WBBA (by 3.5%, p=0.01) and BMC (by 4.8%, p=0.03) than those receiving <10%. Compared to population data, subjects had significantly lower height SDS (−0.41 (SD 1.05)), higher BMI SDS (0.31 (1.33)) and lower LSBMD SDS (−0.29 (1.16)); height and bone mass deficits were greatest in those born SGA with birthweight<1250 g (height SDS −0.81 (0.95), LSBMD SDS −0.61 (1.3)).

Milk vs PTF: Bone Follow-up


90

  “mineral intakes in all groups were markedly below current recommendations”

  “Radial bone mass was significantly higher in subjects who had been randomized to BBM plus MBM than in those who were fed PTF plus MBM, with increasing BMC as the proportion of MBM in the diet increased”

  “comparison of subjects fed BBM or PTF as their sole diet … BA and BMC were consistently higher in the BBM group” (though underpowered to achieve significance)



R. S. Cohen, MD 16

Early Diet & Long-term Bone


91

“… the intake of human milk during the early postnatal period was positively associated with later whole body bone size and bone mass. This finding, which may most plausibly be interpreted as representing a non-nutritive effect of human milk on bone development related to one of the many growth factors or hormones present in human milk, may represent another long-term benefit for human milk, adding to the benefits for later cardiovascular health already documented in this population.”


Changes in milk components with milk expression and mineral supplementation


92

Total Calcium

(mM)

Ionized calcium

(mM)

Non-protein phosphate

(mM)

Bicarbonate (mM)

pH

Fresh Milk1 7.5 3.0 1.8 6.0 6.8

Preterm Donor Milk2

5.7 0 1.8 ~0 7.5

Preterm Donor Milk + Calcium2

50.2 3.1 1.8 ~0 7.0

Preterm Donor Milk + Phosphorus2

5.3 0.04 22 ~0 7.0

1Allen et al. AmJClinNutr 1991; 54:69-80. 2Fogleman AD, et al. JPGN 2012; 55:390–7.

•  Donor breast milk contains less ionized calcium than fresh breast milk because it loses CO2 during expression and processing.

•  Adding supplemental calcium increases ionized calcium in donor breast milk.

0

500

1000

1500

2000

2500

3000

Milk Milk + Calcium Milk + Phosphorus

Milk + Calcium & Phosphorus

Milk + Similac® Human Milk Forti>ier

Milk + Similac Neosure®

Milk + Enfamil EnfaCare®

Insoluble Calcium (μg/mL)

c

a

a

c

b b b

Calcium in vitro - Precipitate


93

Fogleman AD, et al. JPGN 2012; 55:390–7. DOI: 10.1097/MPG.0b013e318254ec07

0

1000

2000

3000

4000

5000

6000

Milk Milk + Calcium Milk + Phosphorus

Milk + Calcium & Phosphorus

Milk + Similac® Human Milk Forti>ier

Milk + Similac Neosure®

Milk + Enfamil EnfaCare®

Total Dialyzed Calcium (μg)

a

b

b, c c c c c

Calcium in vitro - Soluble


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Fogleman AD, et al. JPGN 2012; 55:390–7. DOI: 10.1097/MPG.0b013e318254ec07

Added Calcium vs Milk Protein

Fogleman AD, et al.

ICAN 2012; 4:199-206.

DOI: 10.1177/1941406412452759.

95


Post-discharge Nutrition Around the World


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Klingenberg, C, et al. Arch Dis Child Fetal Neonatal Ed 2012; 97:F56−F61. doi:10.1136/F60 adc.2010.204123


R. S. Cohen, MD 17

Diet vs BMC

97


van de Lagemaat M, et al.

J Nutr 2013; 143:1439-44.

Role of Vit D van de Lagemaat M, et al.

J Nutr 2013; 143:1439-44.

98


“In conclusion, during the first 6 mo postterm, higher vitamin D intake and greater increase in serum 25(OH)D concentration in PDF-fed preterm infants were associated with increased bone accretion.”

Vit D Insufficiency in VLBW


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McCarthy RA, et al. Br J Nutr 2013; 110:156-63.

Response to Vit D 400 IU/d


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McCarthy RA, et al. Br J Nutr 2013; 110:156-63.

Discharge Diet Recommendations


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  Maximize intake of maternal milk   Avoid powdered formulas if possible,   Supplement with PDF 2-3 feeds/d if necessary.

  Give a Multi-vitamin.   Formula fed infants use PDF

  Monitor growth parameters to avoid overgrowth.

  Supplemental Calcium Glubionate & NaKPhosphate   Bad osteopenia,   Chronic furosemide Rx.

Thanks To:


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  Stanford – LPCH:   Olivia Mayer, RD,   Kari McCallie, MD,

  North Carolina:   April D. Fogleman, PhD   Jonathan Allen, PhD

  Mothers’ Milk Bank   Pauline Sakamoto, RN

 in memory of Mary Rose Tully.

fortify placer 14 ho - placer lactation conferences · mat = maternal milk ptf = pre-term formula...

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