沧州市早产儿血清维生素D水平及其母亲认知情况调查分析

目的 了解沧州市早产儿血清维生素D水平及母亲对其影响因素,为防治早产儿佝偻病提供依据。 方法 选取沧州市人民医院158例早产儿进行血清25-(OH)D测定,对其母亲进行相关营养知识问卷调查。结果 早产儿普遍存在维生素D缺乏,维生素D缺乏比例为97.4%,与母亲维生素D认知水平、摄入水平低下密切相关,仅有6.9%的人补充了含维生素D的钙剂,而且服用不规律,未达到中国营养学会对妊娠期孕妇的推荐摄入量要求。 结论临床工作者加强对孕产妇的健康教育,使其认识到合理补充维生素D的重要性。     

RAPID DEVELOPMENT OF VITAMIN K DEFICIENCY IN AN ADOLESCENT BOY RECEIVING TOTAL PARENTERAL NUTRITION FOLLOWING BONE MARROW TRANSPLANTATION

In this case report the development of a vitamin K deficiency in a neutropenic adolescent receiving parenteral nutrition following bone marrow transplantation is described. The parenteral nutrition solution did not provide vitamin K and the patient had been receiving oral antibiotics prior to and during use of the intravenous feeding. Oral intake was minimal. Standard adult oral and intravenous multivitamin preparations for use in individuals older than 11 years do not routinely contain this vitamin. The function of vitamin K and causes for development of a deficiency are reviewed. Recommended intakes and guidelines for supplementation are also discussed.     

Phylloquinone (vitamin K1) intakes and food sources in 18-64-year-old Irish adults

Dietary vitamin K1 (phylloquinone) levels that are sufficient to maintain normal blood coagulation may be sub-optimal for bone, and habitual low dietary intakes of vitamin K may have an adverse effect on bone health. The objective of the present study was to measure the intake and adequacy of phylloquinone intake and the contribution of foods to phylloquinone intake in a nationally representative sample of Irish adults. The North/South Ireland Food Consumption Survey database was used, which contains data collected using a 7 d food diary in a randomly selected sample of Irish adults aged 18-64 years (n 1379; 662 men and 717 women). Phylloquinone intakes were estimated using recently compiled food composition data for phylloquinone. The mean daily intake of phylloquinone from food sources was 79 (SD 44) microg. Intakes were significantly higher (P<0.001) in men than in women at levels of 84 and 75 microg/d. The main contributors to phylloquinone intakes were vegetables (48 %), particularly green vegetables (26 %). Potatoes (including chipped and fried potatoes), dairy products and fat spreads contributed 10 % each and meat contributed 8 %. In men, social class and smoking status influenced phylloquinone intakes. Of the population, 52 % had phylloquinone intakes below 1 microg/kg body weight and only 17 % of men and 27 % of women met the US adequate intakes of 120 and 90 microg/d, respectively. The present study shows that habitual phylloquinone intakes in Irish adults are low, which may have implications for bone health.     

Phylloquinone (vitamin K1) intakes and serum undercarboxylated osteocalcin levels in Irish postmenopausal women

Low phylloquinone (vitamin K1) intakes have been associated with low bone mineral density in older adults. Phylloquinone intakes and serum undercarboxylated osteocalcin (ucOC) levels were assessed in ninety-seven apparently healthy, free-living Irish women aged 50-75 years. Phylloquinone intakes were estimated using a detailed dietary history, which measured habitual food intakes from a typical 14 d period, and recently published food composition data for phylloquinone. Fasting serum ucOC was measured using an enzyme immunoassay. The median daily intake of phylloquinone in the group from all sources was 108.8 microg and from food sources only was 106.6 microg, indicating that approximately 99 % of the phylloquinone came from food. Vegetables and vegetable dishes contributed 67 % of the total phylloquinone intake, but further analysis showed that broccoli, cabbage and lettuce were the primary sources, making a total contribution of 44 %. Twenty per cent of the women had a phylloquinone intake below the UK recommendation of 1 microg/kg body weight per day and 34 % failed to meet the US Adequate Intake value of 90 microg/day. Mean serum ucOC levels in the women were 6.2 (SD 1.7) ng/ml and were predicted by phylloquinone intake (beta -2.20, generated from log-transformed phylloquinone intake data; P=0.04). On the basis of comparisons with both UK recommendations and US Adequate Intakes for phylloquinone, the habitual intakes of phylloquinone in a high proportion of Irish postmenopausal women may not be adequate.     

Hyperalimentation-associated neonatal cholestasis: effect of oral gentamicin

The effect of oral gentamicin on the incidence of parenteral nutrition-associated cholestasis in preterm infants less than 1500 g birth weight was assessed retrospectively. Of 24 patients on parenteral nutrition for more than 10 days, 12 infants who received oral gentamicin (group I) for prophylaxis against neonatal necrotizing enterocolitis were compared to 12 infants who did not (group II). Both mean and peak direct bilirubin levels were significantly higher in group II. The increase in both mean and peak direct bilirubin levels after initiation of total parenteral nutrition (TPN) was significant in group II only. The incidence of cholestasis was significantly higher in group II than in group I. These results suggest that oral gentamicin may have a protective effect against parenteral nutrition-associated cholestasis in the newborn preterm infant.     

Parenteral Protein Decision Support System Improves Protein Delivery in Preterm Infants: A Randomized Clinical Trial

Background

Management of neonatal parenteral protein intake for preterm infants is challenging and requires daily modifications of the dose to account for the infant's postnatal age, birth weight, current weight, and the volume and protein concentration of concurrent enteral nutrition. The objective of this study was to create and evaluate the Parenteral Protein Calculator (PPC), a clinical decision support system to improve the accuracy of protein intake for preterm infants who require parenteral nutrition (PN).

Materials and Methods

We integrated the PPC into the computerized provider order entry system and tested it in a randomized controlled trial (routine or PPC). Infants were eligible if they were ≤3 days old, had a birth weight ≤1500 g, and had no inborn error of metabolism. The primary outcome was the appropriate total protein intake, defined as target protein dose ±0.5 g/kg.

Results

We randomly allocated 42 infants for 221 PN days in the control group and 211 in the PPC group. Total protein intake in the PPC group was more accurate as compared with the control group (appropriate protein dosing: odds ratio = 5.8; 95% CI, 2.7–12.4). Absolute deviation from protein target was 0.41 g/kg (0.24–0.58) lower in the PPC group.

Conclusion

The PPC improved appropriate protein dosing for premature infants receiving PN. Further studies are needed to test whether clinical decision support systems will reduce uremia and improve growth and to replicate similar findings in the cases of other PN nutrients.     

How Close Are We to Achieving Energy and Nutrient Goals for Very Low Birth Weight Infants in the First Week?

Background: Emerging evidence suggests intakes of protein and energy as early as the first week of life in preterm very low birth weight (VLBW) infants are associated with improved neurodevelopment. In response, many neonatal intensive care units (NICUs) have launched new, more aggressive early feeding guidelines. The aim of this study was to evaluate enteral and parenteral energy and macronutrient intakes during the first postnatal week in VLBW infants admitted to NICUs that have introduced more aggressive early feeding guidelines. Materials and Methods: Estimated energy and macronutrient intakes were prospectively collected from VLBW infants fed exclusively mother's own milk and/or parenteral nutrition and compared with expert recommendations. Days to reach full enteral feeds (150 mL/kg/d) and discharge anthropometrics were examined. Results: By days 6 and 7, median protein and lipid intakes, respectively, reached recommended values (3.5 and 3.0 g/kg/d). However, by day 8, many infants remained below recommended intakes for protein (34%), lipid (34%), carbohydrate (68%), and energy (71%). Late‐onset sepsis was associated with a decreased likelihood of reaching full enteral feeds on any given day (hazard ratio, 0.2; 95% confidence interval, 0.1–0.5; P ≤ .0009). There was no significant relationship between week 1 nutrient intakes and anthropometrics at discharge. Conclusion: Despite the introduction of more aggressive early feeding guidelines and improved energy and nutrient intakes compared with literature values, many VLBW infants remain below recommended nutrition goals in the first week.     

New Dutch practice guideline for administration of vitamin K to full-term newborns

Vitamin K-deficiency can cause haemorrhage in newborns and infants from the first hours up to several months after birth. These 'vitamin K deficiency bleedings' (VKDB) can be divided into 3 forms: early (occur in the first hours after birth), classic (first week after birth) and late (between the 2nd and the 12th week of life). The current Dutch vitamin K practice guideline consists of prophylactic administration of 1 mg vitamin K orally directly after birth and a daily dose of 25 μg from day 8 onwards. The current prophylactic treatment provides good protection against VKDB for healthy, breastfed infants. However, the current prophylactic treatment provides insufficient protection for a specific group of infants, namely breastfed infants with defective fat absorption (in cholestasis), leading to less efficient absorption of vitamin K by the body. Anually approximately 5 infants from this group suffer serious haemorrhage. After evaluation of current literature and advice from The Health Council of the Netherlands, vitamin K dosage was adapted for all breastfed infants from day 8 to 3 months (12th week of life) following birth: the daily dose was raised from 25 μg to 150 μg per day.     

Providing the Best Parenteral Nutrition before and after Surgery for NEC: Macro and Micronutrients Intakes

Necrotizing enterocolitis (NEC) is the main gastrointestinal emergency of preterm infants for whom bowel rest and parenteral nutrition (PN) is essential. Despite the improvements in neonatal care, the incidence of NEC remains high (11% in preterm newborns with a birth weight <1500 g) and up to 20–50% of cases still require surgery. In this narrative review, we report how to optimize PN in severe NEC requiring surgery. PN should begin as soon as possible in the acute phase: close fluid monitoring is advocated to maintain volemia, however fluid overload and electrolytes abnormalities should be prevented. Macronutrients intake (protein, glucose, and lipids) should be adequately guaranteed and is essential in each phase of the disease. Composite lipid emulsion should be the first choice to reduce the risk of parenteral nutrition associated liver disease (PNALD). Vitamin and trace elements deficiency or overload are frequent in long-term PN, therefore careful monitoring should be planned starting from the recovery phase to adjust their parenteral intake. Neonatologists must be aware of the role of nutrition especially in patients requiring long-term PN to sustain growth, limiting possible adverse effects and long-term deficiencies.     

Vitamin D Status and Factors Associated with Vitamin D Deficiency during the First Year of Life in Preterm Infants

We aimed to investigate the changes in vitamin D levels and factors associated with vitamin D deficiency (VDD) during the first year of life in Korean preterm infants. We enrolled 333 preterm infants who were born at Kyungpook National University Children’s Hospital between March 2013 and December 2019. 25-hydroxyvitamin D (25-OHD) levels and medical records were collected at birth, 6 months, and 12 months of age. The mean gestational age was 33.4 ± 2.3 weeks and mean 25-OHD levels at birth were 18.2 ± 13.5 ng/mL. The incidence of VDD was 82.8%, 30.6%, and 27.0% at birth, 6 months, and 12 months, respectively. The incidence of severe VDD (25-OHD < 10 ng/mL) was 31.5%, 1.5%, and 0%, at birth, 6 months, and 12 months, respectively. Among infants with severe VDD, the deficiency persisted in 49.6% at 6 months, and 35.3% at 12 months. The strongest predictor of VDD during follow-up was 25-OHD concentration at birth. Vitamin D supplementation at 400 IU/day did not affect vitamin D levels during the first year of life. Therefore, it is important to prevent neonatal VDD through maternal vitamin D supplementation during pregnancy. Further research is needed to determine the optimal vitamin D supplementation dose for Korean preterm infants.     

CaxP and Ca/P in the parenteral feeding of preterm infants

Preterm infants requiring prolonged intravenous feeding frequently develop pathologic fractures and rickets. Infants who receive large amounts of calcium have fewer fractures. This observation led us to determine the maximal amounts of calcium and phosphate that can be added to parenteral nutrition solutions without the precipitation of calcium phosphate and to determine the optimal ratio of calcium to phosphate in these solutions. Clinical observations and in vitro experiments indicate that the product of calcium x phosphate (CaxP) in the dextrose-amino acid solution should not exceed 75 square millimolar (square millimole per square liter) to prevent calcium phosphate precipitation in barium-impregnated silicone rubber catheters and should not exceed 100 square millimolar in solutions administered through peripheral veins. Seven intake and output studies were performed in preterm infants to determine the ratio of calcium to phosphate (Ca/P) in the total parenteral nutrition solutions that minimized urinary losses. A Ca/P ratio of 5.0 minimized the sum of the calcium plus phosphate losses in the urine. However, experience with long-term total parenteral nutrition in preterm infants, awareness of the acute and life-threatening effects of body phosphate depletion, and an unmeasured endogenous enteric calcium secretion all suggest that a Ca/P ratio of approximately 3.0 provides a safer compromise between the acute and serious complications of phosphate deficiency and the chronic problems of fractures and rickets due to calcium deficiency.     

Thiamine Deficiency in a Developed Country

Thiamine is a water‐soluble vitamin implicated in several metabolic processes. Its deficiency, due to prolonged parenteral nutrition without adequate vitamin supplementation, can lead to multiorgan failure characterized by cardiovascular impairment and metabolic acidosis refractory to bicarbonate administration. Only thiamine administration allows the remission of symptoms. We report 2 preterm infants with acute thiamine deficiency due to prolonged parenteral nutrition without adequate vitamin supplementation.     

Parental Refusal of Vitamin K and Neonatal Preventive Services: A Need for Surveillance

Objectives Vitamin K deficiency bleeding (VKDB) in infants is a coagulopathy preventable with a single dose of injectable vitamin K at birth. The Tennessee Department of Health (TDH) and Centers for Disease Control and Prevention (CDC) investigated vitamin K refusal among parents in 2013 after learning of four cases of VKDB associated with prophylaxis refusal. Methods Chart reviews were conducted at Nashville-area hospitals for 2011–2013 and Tennessee birthing centers for 2013 to identify parents who had refused injectable vitamin K for their infants. Contact information was obtained for parents, and they were surveyed regarding their reasons for refusing. Results At hospitals, 3.0% of infants did not receive injectable vitamin K due to parental refusal in 2013, a frequency higher than in 2011 and 2012. This percentage was much higher at birthing centers, where 31% of infants did not receive injectable vitamin K. The most common responses for refusal were a belief that the injection was unnecessary (53%) and a desire for a natural birthing process (36%). Refusal of other preventive services was common, with 66% of families refusing vitamin K, newborn eye care with erythromycin, and the neonatal dose of hepatitis B vaccine. Conclusions for Practice Refusal of injectable vitamin K was more common among families choosing to give birth at birthing centers than at hospitals, and was related to refusal of other preventive services in our study. Surveillance of vitamin K refusal rates could assist in further understanding this occurrence and tailoring effective strategies for mitigation.     

Recommended dietary intakes (RDI) of vitamin K in humans

Vitamin K is essential for the formation of at least three proteins involved in blood clotting as well as of other proteins found in plasma, bone, and kidney. Vitamin K deficiency, however, primarily affects the blood clotting process. Vitamin K is provided both from the diet and from endogenous bacterial synthesis, presumably in roughly equal measure. Because intakes of 0.4 micrograms X kg-1 X d-1 (0.89 nmol X kg-1 X d-1) and probably lower intakes maintain normal clotting activities in healthy neomycin-treated adults, rounded daily recommended dietary intakes (RDI) for essentially all reference 76-kg men and 62-kg women are 45 micrograms (100 nmol) and 35 micrograms (78 nmol) phylloquinone, respectively. Newborn infants are at high risk because breast milk contains inadequate concentrations of vitamin K and their intestines are not yet colonized with vitamin K-producing bacteria. Body reserves of vitamin K are small and turnover rapidly. Hence, supplementation of infants with vitamin K is highly advisable. Increments of vitamin K during pregnancy and lactation are also suggested.     

Nutrient Intake with Early Progressive Enteral Feeding and Growth of Very Low-Birth-Weight Newborns

Early nutrition is one of the most modifiable factors influencing postnatal growth. Optimal nutrient intakes for very preterm infants remain unknown, and poor postnatal growth is common in this population. The aim of this study was to assess nutrient intake during the first 4 weeks of life with early progressive enteral feeding and its impact on the in-hospital growth of very low-birth-weight (VLBW) infants. In total, 120 infants with birth weights below 1500 g and gestational ages below 35 weeks were included in the study. Nutrient intakes were assessed daily for the first 28 days. Growth was measured weekly until discharge. Median time of parenteral nutrition support was 6 days. Target enteral nutrient and energy intake were reached at day 10 of life, and remained stable until day 28, with slowly declining protein intake. Median z-scores at discharge were −0.73, −0.49, and −0.31 for weight, length, and head circumference, respectively. Extrauterine growth restriction was observed in 30.3% of the whole cohort. Protein, carbohydrates, and energy intakes correlated positively with weight gain and head circumference growth. Early progressive enteral feeding with human milk is well tolerated in VLBW infants. Target enteral nutrient intake may be reached early and improve in-hospital growth.     

Belgian Consensus Recommendations to Prevent Vitamin K Deficiency Bleeding in the Term and Preterm Infant

Neonatal vitamin K prophylaxis is essential to prevent vitamin K deficiency bleeding (VKDB) with a clear benefit compared to placebo. Various routes (intramuscular (IM), oral, intravenous (IV)) and dosing regimens were explored. A literature review was conducted to compare vitamin K regimens on VKDB incidence. Simultaneously, information on practices was collected from Belgian pediatric and neonatal departments. Based on the review and these practices, a consensus was developed and voted on by all co-authors and heads of pediatric departments. Today, practices vary. In line with literature, the advised prophylactic regimen is 1 or 2 mg IM vitamin K once at birth. In the case of parental refusal, healthcare providers should inform parents of the slightly inferior alternative (2 mg oral vitamin K at birth, followed by 1 or 2 mg oral weekly for 3 months when breastfed). We recommend 1 mg IM in preterm <32 weeks, and the same alternative in the case of parental refusal. When IM is perceived impossible in preterm <32 weeks, 0.5 mg IV once is recommended, with a single additional IM 1 mg dose when IV lipids are discontinued. This recommendation is a step towards harmonizing vitamin K prophylaxis in all newborns.     

Intake and sources of phylloquinone (vitamin K1): variation with socio-demographic and lifestyle factors in a national sample of British elderly people

Intake and sources of phylloquinone (vitamin K1) were examined according to socio-demographic and lifestyle factors in free-living British people aged 65 years and over, from the 1994-5 National Diet and Nutrition Survey. Complete 4-d weighed dietary records were obtained from 1152 participants living in private households. Using newly-available, mainly UK-specific food content data, the weighted geometric mean intake of phylloquinone was estimated at 65 (95 % CI 62, 67) microg/d for all participants, with higher intakes in men than in women (70 v. 61 microg/d respectively, P<0.01). The mean nutrient densities of phylloquinone intake were 9.3 and 10.5 microg/MJ for men and women respectively (P<0.01), after adjusting for age group, region and smoking status. Of all the participants, 59 % had phylloquinone intakes below the current guideline for adequacy of 1 microg/kg body weight per d. Participants aged 85 years and over, formerly in manual occupations, or living in Scotland or in northern England reported lower phylloquinone intakes than their comparative groups. Overall, vegetables contributed 60 % of total phylloquinone intake, with cooked green vegetables providing around 28 % of the total. Dietary supplements contributed less than 0.5 % of phylloquinone intake. Participants living in northern England or in Scotland, in particular, derived less phylloquinone from vegetables than those living in southern England.     

Time course of vitamin E repletion in the premature infant

Plasma and erythrocyte (RBC) tocopherol-isomer concentrations were determined serially in forty-two premature infants (25-35 weeks gestation) from birth to 8 weeks of age. For comparison purposes vitamin E status was also determined in six term infants over the first 8 d following birth and in a group of thirteen adult volunteers. Vitamin E intakes in term and preterm infants were calculated from recorded food intakes and blood transfusions. In term infants plasma vitamin E concentration rose from 1.9 mg/l (day 1) to 8.2 mg/l by day 8. In comparison preterm plasma vitamin E concentration, 0.3 mg/l (day 1), did not change appreciably by day 8 (0.7 mg/l). Likewise RBC vitamin E concentration increased in term infants from 1.3 mg/l (day 1) to 2.7 mg/l (day 8), while in preterm infants it remained unchanged, 1.5 mg/1 (day 1) v. 1.3 mg/l (day 8). Over the 3 weeks following birth, RBC vitamin E concentrations in the premature infants increased to adult values, while plasma vitamin E concentration did not reach the adult range until 8 weeks post-term. These slow changes in plasma vitamin E status occurred even though the vitamin E intake of these infants was similar to that proving adequate for term infants.     

Development of a self-assessment instrument to determine daily intake and variability of dietary vitamin K

OBJECTIVE: To develop and validate a brief, self-assessment instrument (K-Card) to determine daily variations in dietary vitamin K1 (phylloquinone) intake for use in patients receiving oral warfarin anticoagulant therapy. METHODS: The K-Card was designed to include a checklist of selected common foods and beverages providing > or = 5 microg vitamin K per serving in American diets and items with lower vitamin K content typically consumed in quantities which contribute significantly to total vitamin K intake. The K-Card was validated against records of weighed food intake from thirty-six healthy volunteers, 20 to 40 and 60 to 80 years of age, whose phylloquinone intakes and plasma concentrations had been previously measured by the Metabolic Research Unit, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA USA. Future use of the K-Card by patients was simulated by a single investigator using 108 one-day weighed food records to estimate phylloquinone intakes. Dietary phylloquinone calculated from the K-Card was compared to the values of phylloquinone intake from the diet records collected on the same days, and to fasting plasma phylloquinone concentrations obtained from the same individuals on the following day. RESULTS: The mean dietary phylloquinone intake (+/- SEM) was 138.8 +/- 15.7 microg for the K-Cards compared to 136.0 +/- 15.8 microg for the diet records (p = 0.067). Bland-Altman limits of agreement between quantities of dietary phylloquinone calculated from the K-Card and values obtained from the weighed food records were +/- 38 microg. CONCLUSION: In this simulation, the K-Card provided an accurate estimate of dietary phylloquinone intake and therefore deserves further testing for use by patients receiving coumarin-based anticoagulant therapy to determine whether variability in dietary patterns contributes to disruptions in anticoagulant drug efficacy and safety.     

Vitamin K status of older individuals in northern China is superior to that of older individuals in the UK

To explore whether differences in vitamin K nutrition might, at least in part, underlie differences in fracture incidence between Asian and European populations, the vitamin K status of older individuals in Shenyang, China (eighty-six men, ninety-two women) and in Cambridge, UK (sixty-seven men, sixty-seven women) was compared. Dietary information was collected by food questionnaire in Shenyang and food diary in Cambridge and used to estimate the intake and sources of phylloquinone. Fasting blood was analysed for phylloquinone, triacylglycerol, total osteocalcin (tOC) and undercarboxylated osteocalcin (expressed as percentage of tOC; %ucOC). The mean intakes of green leafy vegetables were 127 (SD 90) g/d in Shenyang and 39 (SD 48) g/d in Cambridge. The estimated phylloquinone intakes (geometric means) were 247 (95% CI 226, 270) microg/d in Shenyang and 103 (95% CI 94, 112) microg/d in Cambridge. Plasma phylloquinone concentrations (geometric means) were significantly higher in the Shenyang subjects (2.17 (95% CI 1.95, 2.42) nmol/l) than in the Cambridge subjects (0.69 (95% CI 0.63, 0.76) nmol/l; P<0.001). Plasma phylloquinone concentration was positively related to phylloquinone intake in both the Shenyang (coefficient 0.17 (SE 0.08); P=0.03) and Cambridge subjects (coefficient 0.29 (SE 0.10); P=0.005). tOC concentration and %ucOC (after adjusting for tOC) were significantly lower in the Shenyang than in the Cambridge subjects (tOC 25.2 (SE 4.2)% and %ucOC 68.5 (SE 10.0)% lower respectively; P<0.001). After adjusting for tOC and triacylglycerol, %ucOC was negatively related to plasma phylloquinone concentration in both the Shenyang (coefficient -0.41 (se 0.11); P=0.0003) and Cambridge subjects (coefficient -0.17 (SE 0.07); P=0.02). The present study demonstrates that older individuals in northern China have a better vitamin K status compared with their British counterparts in Cambridge, UK.