Pain relief for neonates in Australian hospitals: A need to improve evidence-based practice

Objective: To ascertain the extent to which neonatal analgesia was used in Australia for minor invasive procedures as an indicator of evidence-based practice in neonatology. Methods: A cross-sectional telephone survey of hospitals in all Australian states and territories with more than 200 deliveries per year was carried out. Questions were asked regarding awareness of the benefits and the use of analgesia for minor invasive procedures in term and near term neonates. Analysis was undertaken according to state and territory, annual birth numbers and the level of neonatal nursery care available. Results: Data were available from 212 of 214 eligible hospitals. Of the total respondents, 51% and 70% respectively were aware of the benefits of sucrose and breast-feeding for neonatal analgesia. Eleven per cent of units administered sucrose before venepuncture and 25% of units used breast-feeding. Ten per cent of units used sucrose before heel prick with 49% utilizing breast-feeding. Expressed breast milk was used in 10% of units. Analgesia was given less frequently before intravenous cannulation compared to venepuncture and heel prick. Awareness and implementation of neonatal analgesia varied widely in the states and territories. There was a trend for hospitals providing a higher level of neonatal care to have a greater awareness of sucrose as an analgesic (P < 0.0001) and the use of sucrose for venepuncture (P = 0.029), heel prick (P = 0.025) and intravenous catheter insertion (P = 0.013). Similar trends were found on analysis according to birth number of the maternity units. Smaller units had a greater usage of breast-feeding as an analgesic for heel prick (P = 0.017). Conclusion: Despite good evidence for the administration of sucrose and breast milk in providing effective analgesia for newborn infants, it is not widely used in Australia. It is imperative that the gap between research findings and clinical practice with regard to neonatal analgesia be addressed.

Neonatal enteral feeding tubes as loci for colonisation by members of the Enterobacteriaceae

Background The objective of this study was to determine whether neonatal nasogastric enteral feeding tubes are colonised by the opportunistic pathogen Cronobacter spp. (Enterobacter sakazakii) and other Enterobacteriaceae, and whether their presence was influenced by the feeding regime. Methods One hundred and twenty-nine tubes were collected from two neonatal intensive care units (NICU). A questionnaire on feeding regime was completed with each sample. Enterobacteriaceae present in the tubes were identified using conventional and molecular methods, and their antibiograms determined. Results The neonates were fed breast milk (16%), fortified breast milk (28%), ready to feed formula (20%), reconstituted powdered infant formula (PIF, 6%), or a mixture of these (21%). Eight percent of tubes were received from neonates who were 'nil by mouth'. Organisms were isolated from 76% of enteral feeding tubes as a biofilm (up to 107 cfu/tube from neonates fed fortified breast milk and reconstituted PIF) and in the residual lumen liquid (up to 107 Enterobacteriaceae cfu/ml, average volume 250 µl). The most common isolates were Enterobacter cancerogenus (41%), Serratia marcescens (36%), E. hormaechei (33%), Escherichia coli (29%), Klebsiella pneumoniae (25%), Raoultella terrigena (10%), and S. liquefaciens (12%). Other organisms isolated included C. sakazakii (2%),Yersinia enterocolitica (1%),Citrobacter freundii (1%), E. vulneris (1%), Pseudomonas fluorescens (1%), and P. luteola (1%). The enteral feeding tubes were in place between < 6 h (22%) to > 48 h (13%). All the S. marcescens isolates from the enteral feeding tubes were resistant to amoxicillin and co-amoxiclav. Of additional importance was that a quarter of E. hormaechei isolates were resistant to the 3rd generation cephalosporins ceftazidime and cefotaxime. During the period of the study, K. pneumoniae and S. marcescens caused infections in the two NICUs. Conclusion This study shows that neonatal enteral feeding tubes, irrespective of feeding regime, act as loci for the bacterial attachment and multiplication of numerous opportunistic pathogens within the Enterobacteriaceae family. Subsequently, these organisms will enter the stomach as a bolus with each feed. Therefore, enteral feeding tubes are an important risk factor to consider with respect to neonatal infections.

Avaliação do ganho de peso de bebês prematuros em relação ao leite materno cru e leite pasteurizado

This study aims to evaluate the weight gain of premature newborns fed with breast milk from their mothers' from those that are fed with breast milk from the milk bank. The research is the quantitative, descriptive and observational kind. It was conducted in the Neonatal Intensive Care Unit and Housing from the Maternity Hospital Escola Januário Cicco (MEJC), that is a reference for high risk pregnancy and birth in Rio Grande do Norte. The premature newborns included were following these parameters: gestational age from 26 to 37 weeks, initially hospitalized at UTIN, with oral diet, by means by gavage, cup and/or suction. Studies with premature newborns with a zero diet longer than seven days or complications that interfered in the evaluation of weight gain were excluded from this study. The sample was selected for convenience and had data of all newborns hospitalized at UTIN from the May to June of 2014 time period, followed to their discharge, ended by August of 2014 and had the inclusion parameters of the study. From the period of the data collection, 60 premature newborns entered the maternity and 39 of those were the sample of research. The project was approved by the Research Ethics Committee from UFRN, under CAAE nº 0699.0.000.294-11. The data was analyzed by means of descriptive and deduced statistics. The results indicated that the involved in the study, were born from mother with average age of 25,36 years, with less than nine years education 21 (53,8%), had the family income less than a minimum wage 24 (61,5%). Among the newborn, the female gender predominated 20 (51,3%), had cesarean delivery 25 (64,1%), had moderate prematurity 29 (74,5%), more of 1.500g 22 (556,4%). The birth weight average was 1.608,49g. The total of diets were 9.994, and an average of 256 for each newborn, in a 32,12 days of hospitalization time period. Most of the diet supplies were from the breast milk bank (50,34%), however 56,4% of the newborns had most of the diet from their mothers' milked breast milk. It was detected that 38,5% of the newborns had, in some given moment, artificial milk. The daily weight gain average of all newborns was 2,59g, but 35% of them had an average above 10g per day. From the newborn's group (n=25) that had medium weight gain, only 9 of them (36,0%) received mainly their own mothers' milked breast milk. It's been conclusive that most of the premature newborns gained weight predominantly from diets from the breast milk of the Milk Bank, showing the need of a bigger incentive to exclusive breast feeding.

Avaliação da suplementação de vitamina E sobre a concentração de alfa-tocoferol no leite materno em mulheres com partos prematuros

The term vitamin E refers to a group of eight molecular compounds which differ in structure and bioavailability, and the RRR-alpha-tocopherol more biologically active form. The composition of vitamin E in breast milk undergoes variations during lactation, colostrum and milk richer in this micronutrient compared to transitional and mature milk. Newborns, especially premature infants are more susceptible to vitamin E deficiency and to prevent the damage caused by this deficiency has been proposed supplementation of neonates with this micronutrient, however, there is no consensus to carry out this intervention. Thus, maternal supplementation with RRRalpha-tocopherol in the postpartum period can be a good alternative to try to raise the alpha-tocopherol levels in breast milk and therefore provide the premature newborn adequate amounts of vitamin E. This study to evaluate the effect of supplementation with 400 UI acetate RRR-alpha-tocopherol in women with premature births, on the concentration of alpha-tocopherol in breast milk colostrum, transitional and mature. The study included 89 healthy adult women were enrolled in the control group (n = 51) and supplemented group (n = 38). Blood samples were collected and milk colostrum soon after birth (0h milk) twenty-four hours, new rate of colostrum milk was collected (24h milk). The transitional and mature milk were collected in seven days (7d milk) and thirty days (30d milk) after delivery, respectively. Supplementation in the supplemented group was held after the collection of blood and 0h milk. The alpha-tocopherol analyzes were performed by high-performance liquid chromatography. Serum levels of alpha-tocopherol less than 516 μg/dL were considered indicative of nutritional deficiency. The average concentration of alphatocopherol in the serum of the control group mothers was 1159.8 ± 292.4 μg/dL and the supplemented group was 1128.3 ± 407.2 μg/dL (p = 0.281). All women had nutritional status in vitamin E suitable. In both groups, it was observed that the concentration of vitamin E in colostrum milk was higher compared to transitional and mature milk. In the supplemented group, the concentration of alpha-tocopherol in the milk increased 60 % after supplementation, from 1339.3 ± 414.2 μg/dL (0h milk) to 2234.7 ± 997.3 μg/dL (24h milk). While the control group values in colostrum 0h and colostrum 24h were similar (p = 0.681). In the control group the follow-on milk alphatocopherol value was 875.3 ± 292.4 μg/dL and in the group supplemented 1352.8 ± 542.3 μg/dL, an increase of 35% in the supplemented group compared to control (p <0.001). In mature milk alpha-tocopherol concentrations between the control group (426.6 ± 187.5 μg/dL) and supplemented (416.4 ± 214.2 μg/dL) were similar (p = 0.853). Only 24h milk supplemented group answered the nutritional requirement of alpha-tocopherol (4 mg/day) of the newborn. These results show that the transport of this micronutrient for milk occurs in a controlled and limited way. Thus, the native vitamin E supplementation increases the concentration of alpha-tocopherol in colostrum and milk and transition does not influence the concentration in mature milk. Only the increase in colostrum milk was sufficient to meet the nutritional requirement of premature newborns.

Avaliação da concentração de vitamina A materna e de neonatos prematuros e a termo

Vitamin A is an essential nutrient for many physiological processes such as growth and development, so that their adequate nutritional state is essential during pregnancy and lactation. Lactating women and children in breastfeeding are considered risk groups for vitamin A deficiency and some factors may increase the risk of vitamin A deficiency, such as prematurity. The aim of this work was to evaluate the vitamin A concentration in preterm and term lactating women and newborns by determination of retinol in maternal serum, umbilical cord serum and breast milk collected until 72 hours postpartum. 182 mothers were recruited and divided into preterm group (GPT; n = 118) and term group (GT, n = 64). In preterm group were also analyzed transition milk (7th-15th day; n = 68) and mature milk (30th-55th day; n = 46) samples. Retinol was analyzed by high-performance liquid chromatography (HPLC). Maternal retinol concentration in serum was 48.6 ± 12.3 µg/dL in GPT and 42.8 ± 16.3 µg/dL in the GT (p <0.01). Cord serum retinol was 20.4 ± 7.4 µg/dL in GPT and 23.2 ± 7.6 µg/dL in GT (p> 0.05). Among newborns, 43% of premature and 36% of term had low levels of serum retinol in umbilical cord (<20 µg/dL). In colostrum, the retinol in preterm and term groups had an average of 100.8 ± 49.0 µg/dL and 127.5 ± 65.1 µg/dL, respectively (p <0.05). The retinol average in preterm milk increased to 112.5 ± 49.7 µg/dL in transition phase and decreased to 57.2 ± 23.4 µg/dL in mature milk, differing significantly in all stages (p <0.05). When comparing with the recommendation of vitamin A intake (400 µg/day) GT colostrum reached the recommendation for infants, but in GPT the recommendation was not achieved at any stage. Mothers of premature infants had higher serum retinol than mothers at term; however, this was not reflected in serum retinol of umbilical cord, since premature had lower concentration of retinol. Such condition can be explained due to lower maternal physiological hemodilution and placental transfer of retinol to the fetus during preterm gestation. Comparison of retinol in colostrum showed lower concentrations in GPT; however the transition phase there was a significant increase of retinol content released by the mammary gland of preterm mothers. This situation highlights a specific physiological adaptation of prematurity, likely to more contribute to formation of hepatic reserves of retinol in premature infants.

Infant nutrition and the gut microbiota

Establishment of the intestinal microbiota commences at birth and this colonisation is influenced by a number of factors including mode of delivery, gestational age, mode of feeding, environmental factors and host genetics. As this initial establishment may well influence the health of an individual later in life, it is imperative to understand this process. Therefore, this thesis set out to investigate how early infant nutrition influences the development of a healthy gut microbiota. As part of the INFANTMET project, the intestinal microbiota of 199 breastfed infants was investigated using both culture-dependent and culture-independent approaches. This study revealed that delivery mode and gestational age had a significant impact on early microbial communities. In order to understand host genotype-microbiota interactions, the gut microbiota composition of dichorionic triplets was also investigated. The results suggested that initially host genetics play a significant role in the composition of an individual’s gut microbiota, but by month 12 environmental factors are the major determinant. To investigate the origin of hydrogen sulphide in a case of nondrug- induced sulfhemoglobinemia in a preterm infant, the gut microbiota composition was determined. This analysis revealed the presence of Morganella morganii, a producer of hydrogen sulphide and hemolysins, at a relative abundance 38%, which was not detected in control infants. Following on from this, the negative and short term consequences of intrapartum antibiotic prophylaxis exposure on the early infant intestinal microbiota composition were demonstrated, particularly in breast-fed infants, which are recovered by day 30. Finally, the composition of the breast milk microbiota over the first three months of life was characterised. A core of 12 genera were identified amongst women and the remainder comprised some 195 genera which were individual specific and subject to variations over time. The results presented in this thesis have demonstrated that the development of the infant gut microbiota is complex and highly individual. Clear alterations in the intestinal microbiota establishment process in C-section delivered, preterm and antibiotic exposed infants were shown. Taken together, long-term health benefits for infants, particularly those vulnerable groups, may be conferred through the design of probiotic and prebiotic food ingredients and supplements.

The neonatal nurse: advocating for breastfeeding mothers

Accurate information and support from healthcare professionals as well as respect for parental choice are all factors which contribute to effective breastfeeding in the neonatal unit; with this in mind, Colm Darby and Sharon Nurse discuss the potential problems in expressing breast milk and the interventions which might be effective in avoiding them. Advocacy is an inherent part of neonatal nurses' role whilst caring for sick, vulnerable babies. Colm Darby is a male neonatal nurse working in a predominantly female environment and passionately believes in supporting and advocating for mothers who want to provide breast milk for their babies. In this article, CoIm uses Borton's model of reflection to discuss how he acted as an effective advocate for such a mother.

Diet and Probiotics during Pregnancy - Endorsing developmental Programming

Maternal obesity has been shown to increase the risk for adverse reproductive health outcomes such as gestational diabetes, hypertension, and preeclampsia. Moreover, several studies have indicated that overnutrition and maternal obesity adversely program the development of offspring by predisposing them to obesity and other chronic diseases later in life. The exact molecular mechanisms leading to developmental programming are not known, but it has recently been suggested that obesity-related low-grade inflammation, gut microbiota and epigenetic gene regulation (in particularly DNA methylation) participate in the developmental programming phenomenon. The aim of this thesis was to evaluate the effect of diet, dietary counseling and probiotic intervention during pregnancy in endorsing favorable developmental programming. The study population consisted of 256 mother-child pairs participating in a prospective, double-blinded dietary counselling and probiotic intervention (Lactobacillus rhamnosus GG and Bifidobacterium lactis Bb12) NAMI (Nutrition, Allergy, Mucosal immunology and Intestinal microbiota) study. Further overweight women were recruited from maternal welfare clinics in the area of Southwest Finland and from the prenatal outpatient clinic at Turku University Hospital. Dietary counseling was aimed to modify women’s dietary intake to comply with the recommended intake for pregnant women. Specifically, counseling aimed to affect the type of fat consumed and to increase the amount of fiber in the women’s diets. Leptin concentration was used as a marker for obesity-related low-grade inflammation, antioxidant vitamin status as an efficiency marker for dietary counselling and epigenetic DNA methylation of obesity related genes as a marker for probiotics influence. Results revealed that dietary intake may modify obesity-associated low-grade inflammation as measured by serum leptin concentration. Specifically, dietary fiber intake may lower leptin concentration in women, whereas the intakes of saturated fatty acids and sucrose have an opposite effect. Neither dietary counselling nor probiotic intervention modified leptin concentration in women, but probiotics tended to increase children’s leptin concentration. Dietary counseling was an efficient tool for improving antioxidant vitamin intake in women, which was reflected in the breast milk vitamin concentration. Probiotic intervention affected DNA methylation of dozens of obesity and weight gain related genes both in women and their children. Altogether these results indicate that dietary components, dietary counseling and probiotic supplementation during pregnancy may modify the intrauterine environment towards favorable developmental programming.

Effects of early nutrition on the wnt and bone morphogenic protein pathways in the developing intestine

Infant formula is consumed by the majority of infants in the United States for at least part of the first year of life. Infant formula lacks many of the bioactive compounds that are naturally occurring in breast milk. Because of this, there has been an increased interest by the companies that manufacture infant formula to include additives that would potentially allow formula to more closely mimic breast milk activity. One such ingredient currently being added to infant formula is prebiotics. Prebiotics are non-digestible food ingredients that beneficially affect the host by selectively stimulating the growth of specific healthful bacteria in the colon. It is speculated that prebiotics replicate the activity of breast milk oligosaccharides, which through the production of butyrate by intestinal microbiota, may interact with the Wnt/BMP pathways. The Wnt/BMP pathways regulate intestinal stem cells, which determine the growth, development and maintenance of the intestine. Therefore, the objective of this study was to explore the effects that the addition of prebiotics to formula have on the regulation of the Wnt/BMP pathways when fed to neonatal piglets, a model commonly used in the study of infant nutrition. Piglets (n=5) were randomized into sow-reared (SR), fed control formula (F), or fed formula with added prebiotics (F+P). Fructooligosaccharides (FOS) (2 g/L) and polydextrose (PDX) (2 g/L) were chosen as the prebiotics for this study, because this combination had been less studied than other combinations. Ileum and ascending colon were collected at 7 and 14 days-of-age. Dry matter content, pH, and short chain fatty acid (SCFA) content was measured. The mRNA expression of β-catenin, sFRP3, sFRP4, frizzled 6, DKK1 (Wnt pathway), gremlin (BMP pathway), TNF-a, HNF-4α and osteopontin (OPN) was measured by RT-qPCR. Piglets fed the F+P diet had greater acetate concentration and lower pH in the ileum at day 14 and in the colon at day 7 and day 14 than F piglets. Butyrate concentrations were highest in SR with F+P not differing from F in ileum at day 14 and colon at day 7 and day 14. Effects of age were seen in all genes, with the exception of OPN, sFRP-3 and sFRP-4. On day 7, no effect of diet was observed in the ileum, however, mRNA expression of DKK1 and frizzled 6 were greater in F+P than SR (p≤0.05). On day 14, gremlin expression was lower and OPN was greater in the ileum of SR piglets compared to F and F+P. Also on day 14, HNF-4α mRNA expression was greater in both ileum and colon of F+P piglets and sFRP3 mRNA expression was greater in the colon than F or SR . In summary, differences were observed between gene expression of F+P and SR piglet intestines, but the supplementation of 2 g/L scFOS and 2 g/L PDX to formula did not shift expression of genes in the Wnt/BMP pathways to be more similar to SR than F. As the Wnt/BMP pathway is known to exist in a gradient along the crypt-villus axis, with Wnt expression dominating in the crypt region and BMP expression dominating in the villi, it was possible that pooling whole tissue reduced our ability to detect treatment effects that would be concentrated in either region. A method was therefore developed to remove intestinal epithelial cells along the villus-to-crypt axis. Twenty-five-day-old F and SR piglets were euthanized and ileal tissue was collected and placed in a dissociation buffer in a shaking water bath. Exfoliated cells were removed at increasing time points from 5 to 100 minutes in order to remove cells along the villus-to-crypt axis. After the final incubation, remaining mucosal tissue was removed using a sterile glass microscope slide and pooled with the final exfoliated cell isolation. After each cell collection, a section of tissue was fixed in formalin for histomorphological examination. Expression of genes in the Wnt/BMP pathways, along with crypt marker genes (CDK5 and v-myb), were measured in both whole ileal tissue, pooled epithelial cells, and separate epithelial cell isolations from the same piglet. The expression of β-catenin, HNF-4α, TNF-α, TGF-β and the crypt marker v-myb matched the expected villus-to-crypt pattern in cells collected after 10 (incubation 1), 30 (incubation 2) and 60 (incubation 3) minutes. However, expression of expression in cells collected after 100 minutes (incubation 4) was variable, which may be due to the fact that crypt cells were not efficiently removed and the presence of unwanted non-epithelial tissue. Gremlin, OPN, DKK1, sFRP3 and sFRP4 expression was not statistically different along the villus-to-crypt axis. Frizzled 6 and CDK5 did not express as we had predicted, with expression highest towards the villi. In summary, the epithelial cell collection method used was not entirely successful. While much of the gene data suggests that cells were removed along the villus-to-crypt axis through the first three incubations, the last incubation, which involved scraping the tissue, removed non-epithelial components of the mucosa, while leaving the crypts intact. In conclusion, the addition of 2 g/L PDX and 2 g/L scFOS did not cause gene expression of the Wnt/BMP pathways to mirror either F or SR expression. New isolation methods to extract cells along the crypt-villus axis should be considered, including the use of a laser capture microdissection. While this combination of prebiotics did not yield the intended effects, future research should be done on other combinations, such as the inclusion of galactooligosaccharides (GOS), which is commonly added to food products including infant formula.

Conhecimentos e dificuldades das mães face à amamentação

Enquadramento: Devido à elevada prevalência de abandono precoce da amamentação, diversas instituições (e.g., OMS, UNICEF) têm-se preocupado em proteger, promover e apoiar o aleitamento materno um pouco por todo o mundo, defendendo a sua exclusividade durante os primeiros seis meses de vida do bebé, complementado a partir dessa idade pela introdução de alimentos e mantido até aos 2 anos de idade ou mais, se esse for o desejo da mãe. Objetivos: Avaliar os conhecimentos das mães sobre a amamentação; identificar as dificuldades vivenciadas pelas mães em relação à amamentação; analisar a relação entre as variáveis sociodemográficas e obstétricas das mães e os seus conhecimentos e dificuldades sobre a amamentação. Metodologia: Estudo quantitativo, descritivo, analítico, correlacional e de corte transversal, conduzido numa amostra não probabilística de 100 mães de recém-nascidos e/ou lactentes até 1 ano de vida, internadas no serviço de obstetrícia, neonatologia, pediatria e urgência de uma Unidade Local de Saúde do Norte do País. As inquiridas tinham idade mínima de 16 e máxima de 43 anos (M=30,77; Dp=6,356). Foi utilizado um questionário de caraterização sociodemográfica e um questionário de autorrelato da vivência das mães sobre a amamentação, desenvolvido por Sousa (2014). Resultados: Os principais resultados mostraram que 50% das mães consideram possuir bons conhecimentos relativos à amamentação, porém, apenas 39% foram classificadas com bons conhecimentos, enquanto 52% revelaram dificuldades elevadas. Os conhecimentos foram avaliados tendo por base a sinalização correta da importância da amamentação na primeira hora de vida do bebé por 93% das mães, exclusiva até aos 6 meses (28%), a composição do leite materno e composição imunológica 93%, a maioria das mães considerou saber identificar os sinais da pega correta. Relativamente ao horário da amamentação, 62% ainda considera correto amamentar de três em três horas e 14% defende que o bebé deve mamar 10 minutos em cada mama. Os conhecimentos relacionaram-se significativamente com as mães com ensino superior (x2=17,828; p=0,00) e nas que se encontram a amamentar atualmente (UMW=278,000; p=0,01). As dificuldades mais prevalentes associaram-se às fissuras (56,4%), ingurgitamento mamário (38,5%), mastite (3,8%), dor (40%) e dificuldade na pega (60%), tendo-se constatado diferenças estatisticamente significativas associadas ao ingurgitamento mamário, à mastite e abcesso mamário. Exerce influência nas dificuldades das mães, ter sido informada pelo obstetra (UMW=324,000; p=0,02) e não ter expectativas na primeira amamentação (UMW=521,500; p=0,01). Conclusão: O estudo revela bons conhecimentos globais mas dificuldades elevadas, sendo estas as comumente referenciadas noutros estudos. Face a isto, mantem-se necessário apoiar nas dificuldades vividas durante a amamentação, adequando as estratégias de promoção, proteção e apoio ao AM, para que os resultados possam ser bem-sucedidos. Palavras-chave: aleitamento materno, conhecimentos, dificuldades.

Dificuldades no aleitamento materno

Enquadramento: Apesar de o leite materno ser globalmente aceite como o alimento mais completo e efetivo para assegurar a saúde do bebé, além dos claros benefícios para a mãe, continua-se a verificar que a taxa de amamentação está ainda longe da pretendida. Objetivos: Identificar a evidência científica dos determinantes da interrupção do aleitamento materno aos 6 meses de vida do bebé. Métodos: Foi realizada uma revisão sistemática da literatura sobre as dificuldades que levam à interrupção do aleitamento materno aos 6 meses de vida do bebé. Efetuou-se uma pesquisa na PUBMED, The Cochrane Library, Scielo e Google Académic de estudos publicados entre janeiro de 2010 a outubro de 2015, partindo dos critérios de inclusão previamente definidos, os estudos selecionados foram posteriormente avaliados. Dois revisores avaliaram a qualidade dos estudos a incluir, utilizando a grelha para a avaliação crítica de um estudo. Após a avaliação crítica da qualidade, foram incluídos no corpus de estudo 4 artigos com scores entre 87.5% e 95.0%. Resultados: Como metasíntese e seleção da análise dos artigos, inferiu-se que os fatores que levam à interrupção do aleitamento materno aos 6 meses de vida do bebé são: as preocupações com a lactação, perda de peso do bebé, doença da mãe ou a necessidade de tomar medicação, bloqueio dos ductos mamários, problemas relacionados com a gestão psicossocial, conflitos no seu estilo de vida, o posicionamento e pega inadequados, queixa de leite insuficiente ou fraco, dor à amamentação, fissuras, ingurgitamento mamário, a ansiedade materna e o choro da criança. Conclusões: Perante a evidência científica, as causas de abandono do aleitamento materno são multifatoriais e estão associadas à mãe, ao bebé e à saúde. A promoção do aleitamento materno exige programas de educação baseados na evidência, contribuindo para melhoria dos índices nacionais de prevalência da amamentação até, pelo menos aos 6 meses de vida do bebé, que se deseja cada vez mais consentânea com as melhores práticas internacionais. Palavras-Chave: Aleitamento materno; Dificuldades; Interrupção.

Avaliação da suplementação materna com megadose de vitamina A sobre os níveis de retinol e alfa-tocoferol no colostro

The vitamins A and E are recognizably important in the initial stages of life and the newborn depends on nutritional adequacy of breast milk to meet their needs. These vitamins share routes of transport to the tissues and antagonistic effects have been observed in animals after supplementation with vitamin A. This study aimed to verify the effect of maternal supplementation with vitamin A megadose (200,000 UI) in the immediate post-partum on the concentration of alpha-tocopherol in colostrum. Healthy parturient women attended at a public maternity natalensis were recruited for the study and divided into two groups: control (n = 37) and supplemented (n = 36). Blood samples of colostrum and milk were collected until 12 hours after delivery. The women of the supplemented group was administered a retynil palmitate capsule and 24 hours after the first collection was obtained the 2nd sample of colostrum in two groups for analysis of retinol and alpha-tocopherol in milk. The mean retinol concentration of 50,7 ± 14,4 μg/dL (Mean ± standard deviation) and alpha-tocopherol of 1217.4 ± 959 mg/dL in the serum indicate the nutritional status biochemical appropriate. Supplementation with retynil palmitate resulted in increase not only retinol levels in the colostrum of the supplemented group (p = 0.002), but also the concentration of alpha-tocopherol (p = 0.04), changing from 1456.6 ± 1095.8 mg/dL to 1804.3 ± 1432.0 mg/dL (milk 0 and 24 respectively) compared to values in the control group, 984.6 ± 750.0 mg/dL and 1175.0 ± 730.8 mg/dL. The women had different responses to supplementation, influenced by baseline levels of retinol in colostrum. Those with previous by low levels of retinol in colostrum (<60 mg/dL) had increased the concentration of alpha-tocopherol in milk, whereas those with adequate levels (> 60 mg/dL), showed a reduction after supplementation. Supplementation with retinol palmitate is an important intervention in situations of high risk for vitamin A deficiency, when considering the need to maternal supplementation, since the excess vitamin can offer unfavorable interactions between nutrients essential for the mother-child group

Efeito da suplementação materna com palmitato de retinila sobre a concentração de retinol no colostro em condições de jejum e pós-prandial.

Vitamin A is important in many essential body processes and its deficiency results in serious consequences for human health. Breast milk is the only source of this vitamin for children that are exclusively breastfed. Analysis of vitamin A in mother s milk is important because its concentration is related to maternal vitamin A status and to its ingestion by the mother during pregnancy. The aim of the present study was to assess the effect of maternal supplementation with retynil palmitate on the concentration of colostrum retinol under fasting and postprandial conditions. A total of 149 nursing mothers were recruited at the Januário Cicco Maternity School (Natal, Brazil) and allocated to two groups: Comparison (n = 69) and Test (n = 80). Blood and colostrum (in fasting and postprandial conditions) samples were collected up to 24hs after delivery. Serum retinol and colostrum levels were analyzed by high-performance liquid chromatography. The serum retinol level of 41.6 ± 12.7μg/dL (mean ± standard deviation) indicates adequate biochemical nutritional status. Colostrum retinol level was not influenced by serum retinol levels under any of the conditions established. In the colostrum, the retinol concentration in the unsupplemented test group was 67.3 ± 37.7 μg/dL under fasting and 80.3 ± 35.1 μg/dL under postprandial conditions (p<0.05), showing an increase of 19.3%. In the supplemented test group the values were 102.6 ± 57.3 μg/dL and 133.4 ± 78.3 μg/dL under fasting and postprandial, respectively (p<0.05), representing an increase of 30%. Considering that under fasting conditions most of the vitamin A transported to the milk originates in the retinol binding protein (RBP), the postprandial increase in colostrum retinol suggests a different transport mechanism of retinol to maternal milk from that performed by RBP. This situation becomes more evident under supplementation conditions.

Efeito do estado nutricional bioquímico de retinol e alfatocoferol sobre seus níveis em lactantes

Vitamins A and E are essential nutrients in many biological processes, so that their adequate supply to the neonate is crucial. However, the bioavailability of vitamins may be limited by factors such as maternal nutritional status and the interaction between nutrients. This study aimed to investigate the effect of biochemical nutritional status of retinol and alpha-tocopherol levels in serum and colostrum. The study included 103 healthy puerperal women treated at the reference state maternity hospital (Natal-RN). Colostrum and serum samples were collected fasting in the immediate postpartum period and the analysis of retinol and alpha-tocopherol were determined by high-performance liquid chromatography. Specific cutoff points were adopted to characterize the biochemical status of vitamins A and E. For the total group of lactanting women the average concentration of retinol in serum (1.49 ± 0.4 μmol/L-1) and colostrum (2.18 ± 0.8 μmol/L-1), as well as alpha-tocopherol in serum (26.4 ± 8.0 μmol/L-1) and colostrum (26.1 ± 12.8 μmol/L-1), indicated adequate biochemical state. However, when evaluating the individual, was found a high prevalence of deficient serum (15%) and colostrum retinol (50%), and also alphatocopherol in serum (16%) and colostrum (61%). In women with serum retinol ≥ 1.05 μmol/L-1, found an inverse correlation between serum retinol and alpha-tocopherol in colostrum (p = 0.008, r = -0.28). This association was not observed in women with serum retinol <1.05 μmol/L-1. This situation demonstrates for the first time in humans that high physiological levels of serum retinol, without supplementation, can negatively influence the transfer of alpha-tocopherol in breast milk. Although the diagnosis of satisfactory nutritional status lactanting women showed high risk of subclinical deficiency of vitamins A and E from measurements made in the colostrum

Avaliação do retinol em parturientes com diabetes mellitus gestacional no pós parto imediato

Micronutrient deficiencies affect individuals mainly in developing countries, where vitamin A deficiency is a public health problem worldwide more worrying, especially in groups with increased physiological needs such as children and women of reproductive age. Vitamin A is supplied to the body through diet and has an important role in the visual process, cell differentiation, maintenance of epithelial tissue, reproductive and resistance to infection. The literature has demonstrated the relationship between vitamin A and diabetes, including gestational, leading to a risk to both mother and child. Gestational diabetes is any decrease in glucose tolerance of variable magnitude diagnosed each the first time during pregnancy, and may or may not persist after delivery. Insulin resistance during pregnancy is associated with placental hormones, as well as excess fat. Studies have shown that retinol transport protein produced in adipose tissue in high concentrations, this would be associated with resistance by interfering with insulin signaling. Therefore, this study aimed to evaluate the concentration of retinol in serum and colostrum from healthy and diabetic mothers in the immediate postpartum period. One hundred and nine parturient women were recruited, representing seventy-three healthy and thirty-six diabetic. Retinol was extracted and subsequently analyzed by High Performance Liquid Chromatography. Among the results highlights the mothers with gestational diabetes were older than mothers healthy, had more children and a higher prevalence of cases of cesarean section. Fetal macrosomia was present in 1.4% of healthy parturient women and in 22.2% of diabetic mothers. The maternal serum retinol showed an average of 39.7 ± 12.5 mg/dL for healthy parturients 35.12 ± 15 mg/dL for diabetic and showed no statistical difference. It was observed that in the group of diabetic had 17% vitamin A deficiency, whereas in the healthy group, only 4% of the women were deficentes. Colostrum, the concentration of retinol in healthy was 131.3 ± 56.2 mg/dL and 125.3 ± 41.9 mg/dL in diabetic did not differ statistically. This concentration of retinol found in colostrum provides approximately 656.5 mg/day for infants born to healthy mothers and 626.5 mg/day for infants of diabetic mothers, based on a daily consumption of 500 mL of breast milk and need Vitamin A 400 mg/day, thus reaching the requirement of the infant. The diabetic mothers showed significant risk factors and complications related to gestational diabetes. Although no 11 difference was found in serum retinol concentration and colostrum among women with and without gestational diabetes, the individual analysis shows that parturients women with diabetes are 4.9 times more likely to develop vitamin A deficiency than healthy parturients. However, the supply of vitamin A to the newborn was not committed in the presence of gestational diabetes