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Biomedical subjects

R J Shulman

Publications and source records attributed to R J Shulman.

At least 19 recordsLinked to original sources
PubMed2002

Effect of enteral administration of insulin on intestinal development and feeding tolerance in preterm infants: a pilot study.

OBJECTIVE: To determine in a pilot study whether enteral administration of insulin to preterm infants (26-29 weeks of gestational age) would enhance gastrointestinal development and reduce feed intolerance without adverse effects. DESIGN: Eight preterm infants were given 4 U/kg/day insulin enterally from 4 to 28 days of age. Lactase activity was measured at 28 days of age, while measures of feed intolerance were made throughout the hospital stay. The results were compared with those of a matched historical cohort of 80 preterm infants. SETTING: Tertiary care, university affiliated hospital. MAIN OUTCOME MEASURES: Lactase activity and feed intolerance. RESULTS: No adverse effects, such as hypoglycaemia, were observed after administration of insulin. The infants who received insulin had higher lactase activity and less feed intolerance than the controls (30% shorter time to full enteral feeds; fewer gastric residuals per infant). CONCLUSION: These preliminary data suggest that enteral insulin administration may be of benefit in reducing feed intolerance in preterm infants. A randomised, blinded trial is warranted.

Digestive System↗
PubMed2000

New developments in total parenteral nutrition for children.

The field of parenteral nutrition continues to evolve along two major paths: prevention of complications and refining of nutritional needs. Parenteral nutrition-associated liver disease remains a vexing problem. No single factor is to blame; rather, it requires a number of "hits." In the infant, the liver disease primarily appears to be related to prematurity of bile flow and production, infection, lack of enteral feedings, and most recently appreciated, perhaps free radicals. We are able to meet the nutritional needs of our patients, but our knowledge of actual nutritional requirements remains incomplete. Future studies need to define better appropriate intakes and to rigorously test the utility of proposed nutrients such as glutamine.

Child↗
PubMed2000

Feeding tolerance in premature infants fed fortified human milk.

BACKGROUND: To evaluate feeding tolerance in premature infants immediately after the addition of human milk fortifier (HMF) to their expressed human milk diet. METHODS: Data on milk intake, feeding tolerance, and related assessments and growth milestones from a prospective study of feeding strategies in premature infants were analyzed. The database was searched for the first day HMF was added to the feeding of infants receiving human milk exclusively. The following assessments were tabulated for the 5 days before and the 5 days after the addition of HMF: milk intake, the number of episodes of abdominal distension, gastric residual volume (GRV) more than 2 ml/kg and more than 50% of the volume fed in the prior 3 hours. bile-stained gastric residual, emesis or regurgitation, blood in the stool, the number of abdominal radiographs, the number of episodes of apnea and bradycardia, changes in findings in the clinical examination, and the number of hours feeding was withheld. The time to achieve full tube feeding, complete oral feeding, and hospital discharge were recorded. RESULTS: Seventy-six exclusively human milk-fed premature infants (birth weight, 1065+/-18 g; gestational age, 27+/-0.1 weeks; mean +/- SEM) who received HMF beginning 22+/-0.8 days of age were evaluated. There were significant increases in milk intake and in the number of episodes of GRV more than 2 ml/kg and emesis after the addition of HMF. There were no differences in the number of hours feeding was withheld or any other assessment after the addition of HMF. Infants with increases in GRV more than 2 ml/kg and/or emesis after the addition of HMF were not more likely to be delayed in the time to achieve full tube feeding, complete oral feeding, or hospital discharge than infants who did not experience these events. CONCLUSION: These data suggest that, when all feeding and related assessments and the time to achieve important growth milestones are considered, the addition of HMF does not adversely affect the outcome of the premature infant.

Enteral Nutrition↗
PubMed2000

Characterization of the developmental stages of sucking in preterm infants during bottle feeding.

It is acknowledged that the difficulty many preterm infants have in feeding orally results from their immature sucking skills. However, little is known regarding the development of sucking in these infants. The aim of this study was to demonstrate that the bottle-feeding performance of preterm infants is positively correlated with the developmental stage of their sucking. Infants' oral-motor skills were followed longitudinally using a special nipple/bottle system which monitored the suction and expression/compression component of sucking. The maturational process was rated into five primary stages based on the presence/absence of suction and the rhythmicity of the two components of sucking, suction and expression/compression. This five-point scale was used to characterize the developmental stage of sucking of each infant. Outcomes of feeding performance consisted of overall transfer (percent total volume transferred/volume to be taken) and rate of transfer (ml/min). Assessments were conducted when infants were taking 1-2, 3-5 and 6-8 oral feedings per day. Significant positive correlations were observed between the five stages of sucking and postmenstrual age, the defined feeding outcomes, and the number of daily oral feedings. Overall transfer and rate of transfer were enhanced when infants reached the more mature stages of sucking. We have demonstrated that oral feeding performance improves as infants' sucking skills mature. In addition, we propose that the present five-point sucking scale may be used to assess the developmental stages of sucking of preterm infants. Such knowledge would facilitate the management of oral feeding in these infants.

Bottle Feeding↗
PubMed1999

In vivo measurements of glucose absorption in preterm infants.

UNLABELLED: Few data are available regarding the kinetics of glucose absorption in the preterm infant. In order to ascertain the kinetics of glucose absorption in the premature infant and how rate of infusion and concentration affect absorption, jejunal glucose absorption kinetics were measured in 16 preterm infants by infusing 1, 10, and 100 mM glucose solutions in random order. Seventeen infants were perfused with glucose (100 micromol/min) by infusing 67 mM glucose at 1.5 ml/min and 133 mM glucose at 0.75 ml/min to determine the effect of changes in rate of infusion vs. concentration on glucose absorption. Km and Vmax were related to postnatal age. Km was correlated inversely with the percentage of feedings received as human milk. Antenatal administration of glucocorticoids appeared to increase Vmax. The higher infusion rate resulted in greater glucose absorption than the higher concentration glucose solution. CONCLUSIONS: The characteristics of glucose absorption in the preterm infant change with age and are affected by diet, glucocorticoids, and the method of infusion. These data have implications for the feeding of preterm infants.

Absorption↗
PubMed1999

Feeding strategies for premature infants: randomized trial of gastrointestinal priming and tube-feeding method.

BACKGROUND: Data on enteral feeding management of premature infants are limited and often not the subject of randomized clinical trials. Several small studies suggest benefits from the early initiation of feeding, but do not assess the combined effects of time of initiation of feeding, tube-feeding method, and type of milk used. Either singly or in combination, these treatments may affect growth, bone mineralization, biochemical measures of nutritional status, and feeding tolerance, and, ultimately, the duration of hospitalization. METHODS: A total of 171 premature infants, stratified by gestational age (26 to 30 weeks) and diet (human milk or preterm formula) were assigned randomly among four treatment combinations in a balanced two-way design comparing the presence or absence of gastrointestinal (GI) priming for 10 days and continuous infusion versus intermittent bolus tube-feeding. RESULTS: The major outcome, time required for infants to attain full oral feeding, was similar among treatments. GI priming was not associated with any measured adverse effect and was associated with better calcium and phosphorus retention, higher serum calcium and alkaline phosphatase activity, and shorter intestinal transit times. The bolus tube-feeding method was associated with significantly less feeding intolerance and greater rate of weight gain than the continuous method. In addition, the greater the quantity of human milk fed, the lower the morbidity. CONCLUSIONS: Early GI priming with human milk, using the bolus tube-feeding method, may provide the best advantage for the premature infant.

Body Weight↗
PubMed1999

Feeding strategies for premature infants: beneficial outcomes of feeding fortified human milk versus preterm formula.

BACKGROUND: In a large-scale study of feeding strategies in premature infants (early vs later initiation of enteral feeding, continuous vs bolus tube-feeding, and human milk vs formula), the feeding of human milk had more effect on the outcomes measured than any other strategy studied. Therefore, this report describes the growth, nutritional status, feeding tolerance, and health of participating premature infants who were fed fortified human milk (FHM) in comparison with those who were fed exclusively preterm formula (PF). METHODS: Premature infants were assigned randomly in a balanced two-way design to early (gastrointestinal priming for 10 days) versus late initiation of feeding (total parenteral nutrition only) and continuous infusion versus intermittent bolus tube-feeding groups. The type of milk was determined by parental choice and infants to receive their mother's milk were randomized separately from those to receive formula. The duration of the study spanned the entire hospitalization of the infant. To evaluate human milk versus formula feeding, we compared outcomes of infants fed >50 mL. kg-1. day-1 of any human milk (averaged throughout the hospitalization) with those of infants fed exclusively PF. Growth, feeding tolerance, and health status were measured daily. Serum indices of nutritional status were measured serially, and 72-hour nutrient balance studies were conducted at 6 and 9 weeks postnatally. RESULTS: A total of 108 infants were fed either >50 mL. kg-1. day-1 human milk (FHM, n = 62) or exclusively PF (n = 46). Gestational age (28 +/- 1 weeks each), birth weight (1.07 +/- 0.17 vs 1.04 +/- 0.19 kg), birth length and head circumference, and distribution among feeding strategies were similar between groups. Infants fed FHM were discharged earlier (73 +/- 19 vs 88 +/- 47 days) despite significantly slower rates of weight gain (22 +/- 7 vs 26 +/- 6 g. kg-1. day-1), length increment (0.8 +/- 0.3 vs 1.0 +/- 0.3 cm. week-1), and increment in the sum of five skinfold measurements (0.86 +/- 0.40 vs 1.23 +/- 0.42 mm. week-1) than infants fed PF. The incidence of necrotizing enterocolitis and late-onset sepsis was less in the FHM group. Overall, there were no differences in any measure of feeding tolerance between groups. Milk intakes of infants fed FHM were significantly greater than those fed PF (180 +/- 13 vs 157 +/- 10 mL. kg-1. day-1). The intakes of nitrogen and copper were higher and magnesium and zinc were lower in group FHM versus PF. Fat and energy absorption were lower and phosphorus, zinc, and copper absorption were higher in group FHM versus PF. The postnatal retention (balance) surpassed the intrauterine accretion rate of nitrogen, phosphorus, magnesium, zinc, and copper in the FHM group, and of nitrogen, magnesium, and copper in the PF group. CONCLUSIONS: Although the study does not allow a comparison of FHM with unfortified human milk, the data suggest that the unique properties of human milk promote an improved host defense and gastrointestinal function compared with the feeding of formula. The benefits of improved health (less sepsis and necrotizing enterocolitis) associated with the feeding of FHM outweighed the slower rate of growth observed, suggesting that the feeding of FHM should be promoted actively in premature infants.

Animals↗
PubMed1998

Early feeding, feeding tolerance, and lactase activity in preterm infants.

OBJECTIVE: We sought to ascertain whether the timing of feeding initiation affected the development of intestinal lactase activity and whether there are clinical ramifications of lower lactase activity. STUDY DESIGN: Preterm infants (26 to 30 weeks' gestation; n = 135) were randomly assigned to begin enteral feedings at either 4 (early group) or 15 days of age (standard group). At 10, 28, and 50 days of age lactase activity was determined by measuring the urinary ratio of lactulose/lactose after the 2 sugars were administered. RESULTS: Lactase activity increased significantly over time. Infants in the early group had greater lactase activity at 10 days of age (by 100%) and 28 days of age (by 60%) than the standard group. At 10 days of age lactase activity was greater in milk- versus formula-fed infants. The time required to achieve full enteral feedings, the number of abnormal abdominal x-ray examinations, and the total number of abdominal x-ray examinations were inversely related to lactase activity. CONCLUSIONS: Early feeding increases intestinal lactase activity in preterm infants. Lactase activity is a marker of intestinal maturity and may influence clinical outcomes. Whether the effects of milk on lactase activity were due to the greater concentration of lactose in human milk compared with that in formula must be determined.

Age Factors↗
PubMed1998

Early feeding, antenatal glucocorticoids, and human milk decrease intestinal permeability in preterm infants.

To determine the effects of age, feeding regimen, and antenatal glucocorticoids on intestinal permeability, preterm infants (n = 132) were stratified by gestational age and by diet (mothers' own milk versus preterm formula), and assigned randomly to one of four feeding regimens: early-continuous, early-bolus, standard-continuous, and standard-bolus. At 10, 28, and 50 d of age permeability was determined by measuring the ratio of lactulose/ mannitol in the urine after the two sugars were administered enterally for 30 h. The mean (+/-SE) birth weight and gestational age of the infants were 1044 +/- 13 g and 27 +/- 0.1 wk, respectively. Permeability changed as a function of age (p = 0.003). Early feeding was associated with a reduction in permeability at 10 d of age (p = 0.01). Antenatal steroid administration was associated with decreased permeability at 28 d of age (p = 0.017). The feeding of human milk (versus formula) was associated with decreased permeability at 28 d of age (p = 0.02). Continuous versus bolus feeding did not affect permeability.

Aging↗
PubMed1997

Oral feeding in low birth weight infants.

To gain a better understanding of the development of sucking behavior in low birth weight infants, the aims of this study were as follows: (1) to assess these infants' oral feeding performance when milk delivery was unrestricted, as routinely administered in nurseries, versus restricted when milk flow occurred only when the infant was sucking; (2) to determine whether the term sucking pattern of suction/ expression was necessary for feeding success; and (3) to identify clinical indicators of successful oral feeding. Infants (26 to 29 weeks of gestation) were evaluated at their first oral feeding and on achieving independent oral feeding. Bottle nipples were adapted to monitor suction and expression. To assess performance during a feeding, proficiency (percent volume transferred during the first 5 minutes of a feeding/total volume ordered), efficiency (volume transferred per unit time), and overall transfer (percent volume transferred) were calculated. Restricted milk flow enhanced all three parameters. Successful oral feeding did not require the term sucking pattern. Infants who demonstrated both a proficiency > or = 30% and efficiency > or = 1.5 ml/min at their first oral feeding were successful with that feeding and attained independent oral feeding at a significantly earlier postmenstrual age than their counterparts with lower proficiency, efficiency, or both. Thus a restricted milk flow facilitates oral feeding in infants younger than 30 weeks of gestation, the term sucking pattern is not necessary for successful oral feeding, and proficiency and efficiency together may be used as reliable indicators of early attainment of independent oral feeding in low birth weight infants.

Bottle Feeding↗
PubMed1997

Determinants of lactose digestion in the miniature pig.

Although lactose is an important nutrient in the diet of the infant and child, the factors contributing to its digestion have not been clarified adequately. We sought to determine the degree to which lactase activity and small intestinal transit explain lactose digestion, the average error (SEE) in estimating lactose digestion using these parameters, and the effect of age. We compared lactose digestion from both a 7% lactose-containing formula and a solution by determining lactose in ileostomy output in pig littermates at 10 days, 4 weeks, and 10 weeks of age. The entire small intestinal mucosa was assayed for lactase specific activity (micromol x min-1 x g protein-1), total activity (micromol x min-1), and whole-villus lactase activity. Transit time (min), and transit rate (cm/min) were measured. Meal type did not affect lactose digestion. Lactose digestion was explained best by lactase specific activity (formula, R2 = 0.73, SEE = 1.1; solution, R2 = 0.69, SEE = 1.0; P < 0.001). The next best parameter was total transit rate (formula, R2 = 0.69, SEE = 2.0; solution, R2 = 0.46, SEE = 1.3). The relationship with lactase specific activity was age related and there appeared to be a critical value of lactase specific activity above which essentially all the lactose was digested.

Aging↗
PubMed1996

Effect of carbohydrates on calcium absorption in premature infants.

Premature infants are susceptible to disease related to deficient dietary calcium intake. Studies in adults suggest carbohydrates can enhance calcium absorption. However, little is known about how carbohydrates affect calcium absorption in premature infants due to a lack of direct in vivo studies. We adapted the triple lumen perfusion method for use in premature infants to compare calcium absorption 36 mmol/L (1.44 g/L) in the absence and presence of either 70 g/L lactose or glucose polymers. 44Ca was added to determine endogenous calcium losses. Fourteen infants were studied (gestational age: 31 +/- 0.4 wk; study weight: 1590 +/- 105 g; mean +/- SEM). Calcium absorption from the glucose polymer solution was greater than that from the control and lactose solutions (0.17 +/- 0.05 mumol.min-1.cm-1 versus 0.04 +/- 0.04 and 0.008 +/- 0.045 mumol.min-1.cm-1, respectively). Calcium absorption correlated positively with water and carbohydrate absorption. The rate of carbohydrate absorption was greater from the glucose polymers than from the lactose solution (0.40 +/- 0.10 mg.min-1.cm-1 versus 0.22 +/- 0.06, respectively). Based upon 44Ca absorption, endogenous calcium loss appeared to account for less than 1% of total calcium flux. We conclude that glucose polymers, but not lactose, enhance calcium absorption in the premature infant, a fact that may be useful in formula design.

Calcium, Dietary↗