Human milk feeding appears to decrease intestinal permeability and thereby promote intestinal matu- ration [ 3, 25, 31 ] . However, natural mother’s milk feeds are rare in preterm infant care. Preterm infants can avoid formula feeding, but, to do so with adequate growth, they receive parenteral nutri- tion and bovine- and/or human-based human milk forti fi ers [ 36 ] . Additionally, donor human milk is often used to avoid formula when mother’s milk supply is inadequate or contraindicated [ 56 ] . Evaluation of the effect of these nutrition practices on preterm infant intestinal permeability is the required next step to optimize nutritional practices for anthropometrical growth, neurodevelopment, and intestinal maturation. Previous studies of intestinal permeability by feeding type include human milk with bovine forti fi cation and donor human milk but without regard to effect of these supplements [ 3, 25, 31 ] . Recent report of decreased NEC with intake of human-based human milk forti fi er when compared to bovine-based human milk forti fi er suggests a difference in intestinal health dependent on forti fi er exposure [ 57 ] . For donor human milk, the pasteurization process may decrease the activity of crucial growth factors and immune modulators and, thereby, afford less gut protection than mother’s
milk [ 56 ] . In regard to parenteral nutrition, animal studies demonstrate that colostrum feeds are not as protective against NEC when also receiving parenteral nutrition [ 58 ] . Evaluation of gastrointestinal health with these common nutritional practices is warranted and represents the next stage of preterm infant intestinal permeability science.
Conclusion
As evidence grows in regard to the importance of the gastrointestinal barrier in numerous health outcomes, understanding how the preterm infant’s gastrointestinal system matures without the natural amniotic environment is essential to understanding the infant’s health. Studies point to increased intestinal permeability for preterm infants compared to term infants, but not necessarily related to degree of prematurity. Human milk feeding improves intestinal permeability measurements. Early feedings may or may not lead to earlier gut maturation, but at least do not appear associated with gastrointestinal damage. Evaluation of human milk growth factors such as glutamine and IGF-1, and evaluation of commensal organism stimulators such as prebiotics and probiotics demonstrate equivo- cal results and require further study. Additionally, as new factors in intestinal barrier function, such as NO, are revealed, randomized, controlled trials of intestinal permeability provide an opportunity to measure clinical outcomes. Similarly, current nutritional practices such as parenteral nutrition, donor human milk, and bovine- and human-based human milk forti fi er warrant evaluation of their role in intestinal maturation. Intestinal permeability research demonstrates that, despite the importance of in utero intestinal growth, the majority of preterm infants develop an adequate intestinal barrier.
As commonly found in preterm infant health, human milk as a substitute for amniotic fl uid provides the best opportunity for normal development and avoidance of disease.
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145 R.R. Watson et al. (eds.), Nutrition in Infancy: Volume 1, Nutrition and Health,
DOI 10.1007/978-1-62703-224-7_10, © Springer Science+Business Media New York 2013 N.A. Rodriguez, Ph.D., A.P.N., N.N.P-B.C. (*)
Evanston Hospital , NorthShore University HealthSystem , Evanston , IL 60201 , USA e-mail: [email protected]
Key Points
Human colostrum may have potential immunomodulatory effects.
•
Preterm colostrum is a potential immune therapy for extremely premature infants.
•
The costs of prematurity-associated morbidities may be reduced with early administration of
•
colostrum to extremely premature infants.
The oropharyngeal administration of colostrum is feasible, easy, and cost-effective.
•
Keywords Human colostrum • Breastmilk • Prematurity • Immunomodulation • Oropharyngeal administration
Introduction
Extremely low birth weight (ELBW: birthweight <1,000 g) infants represent the smallest and sickest of the premature population. Despite dramatic advances in neonatal medicine and technology which have signi fi cantly decreased mortality, survivors are burdened with signi fi cant morbidity associated with prematurity-related diseases [ 1– 3 ] . Of particular concern are nosocomial infections such as bac- teremia, ventilator-associated pneumonia (VAP), and a potentially lethal gastrointestinal infectious and in fl ammatory disorder known as necrotizing enterocolitis (NEC). These morbidities are highly prevalent, costly, increase the length of hospitalization, and are associated with a potential for adverse neurodevelopmental outcomes in survivors [ 4– 6 ] .
Human milk, particularly colostrum (early milk) contains a multitude of immunologically derived factors [ 7– 29 ] that protect against nosocomial infections. Colostrum expressed by mothers who deliver ELBW infants, (preterm colostrum) is more highly concentrated in protective factors when compared to colostrum expressed at a later gestation [ 30– 38 ] . As such, preterm colostrum is potentially an “immune therapy” for the immunode fi cient ELBW infant, especially in the fi rst days post-birth. Unfortunately, clinical instability typically precludes enteral feeds in the fi rst days of life and the administration of colostrum is delayed several days until enteral feeds can be safely introduced. An alternative method of administering colostrum, as a potential immune therapy, is needed. Oropharyngeal administration is a feasible alternative [ 39– 44 ] . This chapter is organized into the following sections: (1) Extremely
Colostrum as a Therapeutic for Premature Infants
Nancy A. Rodriguez
Premature Infants and Nosocomial Infections, (2) Protection against Infection with Human Milk, (3) Preterm Colostrum: Implications for the Extremely Premature Infant, (4) Preterm Colostrum as a Potential Immune Therapy, (5) Oropharyngeal Administration of Colostrum.