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Dr. Jobe, Cincinnati: The issue that needs to be considered is a rapid increase in feeds after a period of starvation may lead to an increase in NEC. The point with feeding is to start early.
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(Dr. Adamkin) I agree.
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(Dr. Lucas) In animal studies, it takes 3 days of deprived feeds to produce really significant atrophic changes in the gut, and there is some indirect evidence to show that it is true in humans.
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Robin Ivan from Los Angeles: David, would we change your rule from 1?g of protein per 23 calories to 1 to 15 or something now based on the evidence?
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(Dr. Adamkin) Yes, I think once you achieve 50 nonprotein energy calories, you can maximize your protein dose.
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Dr. Lucas: it looks like from your talk that not all formulas are the same, so what advice would you give to the practicing neonatologists regarding formulas with PUFAs?
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Given that this is a CME-credit meeting, I cannot advise you on a specific product ethically. One needs to look very carefully through the evidence on the available products. I worry about palmitate, for instance, and most of your products here in this country are relatively low in that. Nucleotides are looking very interesting now in formulas, but you need to look at the research data. LC-PUFAs, you want to choose formulas that are being well researched with products that have been shown to be safe and effective.
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Sekar, University of Oklahoma: Both Dr. Lucas and David, thank you for such eloquent presentations. Could you comment on the stock solution that you have in your nursery, the amino acid/glucose? Also, we often add fat to increase the caloric intake and do not worry too much about protein. What is your feeling on 30-calorie formula or the addition of MCT oil or microlipids?
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(Dr. Adamkin) For early TPN, we have stock solutions that have either D5 or D10. It is absolutely critical to maintain protein when you make hypercaloric feedings. Simply adding oils and glucose dilutes protein, and those formulas were designed to be fed at 180?mL/kg/day. When you feed them at 100 or 120 when they are hypercaloric, you are losing out on all of those micronutrients as well.
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Adding something to that — that couldn’t be more right that one of the gut reactions to babies who are not growing is to give them more energy, LCT, MCT, polycose, and the best you can possibly achieve there is more fat deposition.
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What is your strategy for feeding IUGR babies?
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As far as term SGA babies are concerned, the important thing is clearly not to actually promote rapid catch-up growth because that appears to be deleterious. The problem is that a large number of SGA babies spontaneously increase their drive and catch up anyway, whatever you do, even on human milk. As far as SGA preterm infants are concerned, those data are only weeks old where we showed the interaction with an adverse effect on cognitive development if we fed them a high nutrient diet. I don’t think, as I mentioned, we have enough data to treat them differently, but as further data comes out, it may well be that we have to have a different nutritional policy for SGA preemies compared with AGA preemies.
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Our problem with TPN have been aluminum contamination, and even at very low levels, we’re finding out that the aluminum we’re giving our babies with the best solutions are about double what the FDA says are the limits. But what is your personal opinion?
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Our New England Journal of Medicine paper showed that on standard TPN versus specially source low aluminum TPN, you lost one mental development index point for every day of routine TPN 18 months later. Obviously the aluminum issue is very serious indeed, and one does need to get rid of it, and the best way to get rid of it is to get rid of calcium gluconate and change that to calcium chloride. For the future, what you have to do in the United States is what's done in Europe and in Canada to some extent and, that is, to use organic phosphorus sources because once you use organic sources of phosphorus, then you can actually get intrauterine rates of calcium and phosphorus into babies that you can’t get anywhere near with inorganic sources.
Dr. Jobe, Cincinnati: The issue that needs to be considered is a rapid increase in feeds after a period of starvation may lead to an increase in NEC. The point with feeding is to start early.