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Dairy Cows, Famines, and What Neonatologists Can Learn from Them
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Foreword Dairy Cows, Famines, and What Neonatologists Can Learn from Them
Lucky Jain, MD, MBA Consulting Editor
Newborn calves deprived of their mother’s milk early in life seldom survive, even if they are fed a perfectly balanced artificial formula. They die of overwhelming infections because cows rely on their colostrum to transfer a vast array of antibodies to their calves in the first few hours of life. Days after birth, this cycle continues, with cows gaining important colonization information about their babies by licking them and then transferring antibodies specific to those pathogens in their milk. Pretty remarkable adaptation to a situation where transplacental transfer of antibodies is limited. Farmers who raise cattle know this biologic secret well and make sure that newborn calves receive plenty of mother’s milk, even in regions where milk is a scarce commodity. While the impact of mother’s milk deprivation is not as striking in humans, a respectable body of literature confirms significant advantages attached to breast milk. These benefits vary from lower mortality (in breast-fed babies born in nations with poor alternatives to mother’s milk) to softer cognitive and immune benefits in resource-rich nations with safe hygienic conditions and optimally balanced formulas. How mother’s milk achieves these remarkable biologic effects was poorly understood for a long time, with benefits limited to associations seen mostly through epidemiologic data. Recent studies provide strong biologic models for how these effects are achieved. Extracellular vesicles in milk, for example, harbor a variety of compounds, including lipids, proteins, noncoding RNAs, and messenger RNAs that have the capability of mediating subtle but important changes in the newborn.1 Exosomes are particularly important because they carry a tightly regulated message and play an essential role in cell-to-cell communication. Encapsulation in exosomes confers protection against enzymatic and nonenzymatic degradation of biologic messengers and provides a pathway for their cellular uptake by endocytosis of exosomes. Evidence suggests Clin Perinatol - (2016) -–http://dx.doi.org/10.1016/j.clp.2016.12.002 0095-5108/16/ª 2016 Published by Elsevier Inc.
perinatology.theclinics.com
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Foreword
Box 1 Suggested benefits of human-milk feeding for preterm infants Dose-related decreases in NICU length of stay and lower morbidity including risk of the following: Sepsis Necrotizing enterocolitis Urinary tract infection Benefits persist beyond NICU stay Improved gastrointestinal function and integrity via the following: Decreased gastric pH Increased gastrointestinal motility Accelerated mucosal immunity Improved gut microflora Decreased mucosal permeability leading to reduced bacterial translocation Improvement in indexes of neurodevelopment that persists into adolescence Adapted from Raiten DJ, Steiber AL, Hand RK. Executive summary: evaluation of the evidence to support practice guidelines for nutritional care of preterm infants-the Pre-B Project. Am J Clin Nutr 2016;103(2):604S.
that exosomes in milk are transported by a variety of cells and are delivered to peripheral tissues to mediate distal tissue effects. Low concentrations of dietary microRNAs may alter gene expression. Such biologic pathways could then begin to explain the observed advantages in breastfed infants such as higher Mental Developmental Index, Psychomotor Development Index, and Preschool Language Scale-3 than in those fed nutritionally equivalent formulas. The biologic pathways that decrease the risk of necrotizing enterocolitis are also well described. Human milk is believed to compensate for the immature systems by lowering gastric pH, enhancing intestinal motility, decreasing epithelial permeability, and altering the composition of bacterial flora.2 These and other benefits of breast milk are summarized in Box 1.3 Yet, large swaths of communities have moved away from breastfeeding, and the rigorous requirements of today’s workforce make it harder for young mothers to keep up with round-the-clock demands on a breastfeeding mother’s time. Societies and the medical community will need to come up with new strategies to promote and sustain a strong breastfeeding culture.4 This issue of Clinics in Perinatology focuses entirely on human milk feeding in preterm infants. Drs Mimouni and Koletzko are to be congratulated for bringing together a superb set of state-of-the-art articles on this topic. As always, I am grateful to the editors, authors, and the publishing team at Elsevier (Kerry Holland and Casey Potter) for their superb assistance. Lucky Jain, MD, MBA Emory University School of Medicine Department of Pediatrics Children’s Healthcare of Atlanta 2015 Uppergate Drive Atlanta, GA 30322, USA E-mail address: [email protected]
Foreword
REFERENCES
1. Zempleni J, Aguilar-Lozano A, Sadri M, et al. Biological activities of extracellular vesicles and their cargos from bovine and human milk in humans and implications for infants. J Nutr 2016. [Epub ahead of print]. 2. Maffei D, Schanler RJ. Human milk is the feeding strategy to prevent necrotizing enterocolitis! Semin Perinatol 2016. [Epub ahead of print]. 3. Raiten DJ, Steiber AL, Hand RK. Executive summary: evaluation of the evidence to support practice guidelines for nutritional care of preterm infants-the Pre-B Project. Am J Clin Nutr 2016;103(2):599S–605S. 4. Rollins NC, Bhandari N, Hajeebhoy N, et al. Lancet Breastfeeding Series Group. Why invest, and what it will take to improve breastfeeding practices? Lancet 2016;387:491–504.
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Foreword Dairy Cows, Famines, and What Neonatologists Can Learn from Them
Lucky Jain, MD, MBA Consulting Editor
Newborn calves deprived of their mother’s milk early in life seldom survive, even if they are fed a perfectly balanced artificial formula. They die of overwhelming infections because cows rely on their colostrum to transfer a vast array of antibodies to their calves in the first few hours of life. Days after birth, this cycle continues, with cows gaining important colonization information about their babies by licking them and then transferring antibodies specific to those pathogens in their milk. Pretty remarkable adaptation to a situation where transplacental transfer of antibodies is limited. Farmers who raise cattle know this biologic secret well and make sure that newborn calves receive plenty of mother’s milk, even in regions where milk is a scarce commodity. While the impact of mother’s milk deprivation is not as striking in humans, a respectable body of literature confirms significant advantages attached to breast milk. These benefits vary from lower mortality (in breast-fed babies born in nations with poor alternatives to mother’s milk) to softer cognitive and immune benefits in resource-rich nations with safe hygienic conditions and optimally balanced formulas. How mother’s milk achieves these remarkable biologic effects was poorly understood for a long time, with benefits limited to associations seen mostly through epidemiologic data. Recent studies provide strong biologic models for how these effects are achieved. Extracellular vesicles in milk, for example, harbor a variety of compounds, including lipids, proteins, noncoding RNAs, and messenger RNAs that have the capability of mediating subtle but important changes in the newborn.1 Exosomes are particularly important because they carry a tightly regulated message and play an essential role in cell-to-cell communication. Encapsulation in exosomes confers protection against enzymatic and nonenzymatic degradation of biologic messengers and provides a pathway for their cellular uptake by endocytosis of exosomes. Evidence suggests Clin Perinatol - (2016) -–http://dx.doi.org/10.1016/j.clp.2016.12.002 0095-5108/16/ª 2016 Published by Elsevier Inc.
perinatology.theclinics.com
ii
Foreword
Box 1 Suggested benefits of human-milk feeding for preterm infants Dose-related decreases in NICU length of stay and lower morbidity including risk of the following: Sepsis Necrotizing enterocolitis Urinary tract infection Benefits persist beyond NICU stay Improved gastrointestinal function and integrity via the following: Decreased gastric pH Increased gastrointestinal motility Accelerated mucosal immunity Improved gut microflora Decreased mucosal permeability leading to reduced bacterial translocation Improvement in indexes of neurodevelopment that persists into adolescence Adapted from Raiten DJ, Steiber AL, Hand RK. Executive summary: evaluation of the evidence to support practice guidelines for nutritional care of preterm infants-the Pre-B Project. Am J Clin Nutr 2016;103(2):604S.
that exosomes in milk are transported by a variety of cells and are delivered to peripheral tissues to mediate distal tissue effects. Low concentrations of dietary microRNAs may alter gene expression. Such biologic pathways could then begin to explain the observed advantages in breastfed infants such as higher Mental Developmental Index, Psychomotor Development Index, and Preschool Language Scale-3 than in those fed nutritionally equivalent formulas. The biologic pathways that decrease the risk of necrotizing enterocolitis are also well described. Human milk is believed to compensate for the immature systems by lowering gastric pH, enhancing intestinal motility, decreasing epithelial permeability, and altering the composition of bacterial flora.2 These and other benefits of breast milk are summarized in Box 1.3 Yet, large swaths of communities have moved away from breastfeeding, and the rigorous requirements of today’s workforce make it harder for young mothers to keep up with round-the-clock demands on a breastfeeding mother’s time. Societies and the medical community will need to come up with new strategies to promote and sustain a strong breastfeeding culture.4 This issue of Clinics in Perinatology focuses entirely on human milk feeding in preterm infants. Drs Mimouni and Koletzko are to be congratulated for bringing together a superb set of state-of-the-art articles on this topic. As always, I am grateful to the editors, authors, and the publishing team at Elsevier (Kerry Holland and Casey Potter) for their superb assistance. Lucky Jain, MD, MBA Emory University School of Medicine Department of Pediatrics Children’s Healthcare of Atlanta 2015 Uppergate Drive Atlanta, GA 30322, USA E-mail address: [email protected]
Foreword
REFERENCES
1. Zempleni J, Aguilar-Lozano A, Sadri M, et al. Biological activities of extracellular vesicles and their cargos from bovine and human milk in humans and implications for infants. J Nutr 2016. [Epub ahead of print]. 2. Maffei D, Schanler RJ. Human milk is the feeding strategy to prevent necrotizing enterocolitis! Semin Perinatol 2016. [Epub ahead of print]. 3. Raiten DJ, Steiber AL, Hand RK. Executive summary: evaluation of the evidence to support practice guidelines for nutritional care of preterm infants-the Pre-B Project. Am J Clin Nutr 2016;103(2):599S–605S. 4. Rollins NC, Bhandari N, Hajeebhoy N, et al. Lancet Breastfeeding Series Group. Why invest, and what it will take to improve breastfeeding practices? Lancet 2016;387:491–504.
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