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Indian Pediatr 2011;48: 889-891 |
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Vitamin E Supplementation in Exclusively
Breastfed VLBW Infants |
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Smita Tripathi, TK Mishra and *NB Mathur
From the Departments of Biochemistry and *Pediatrics,
Maulana Azad Medical College, New Delhi, India.
Correspondence to: Dr Smita Tripathi, C4/22, Safdarjung
Development Area, New Delhi 110016, India.
Email:
[email protected]
Received: July 06, 2010;
Initial review: July 26, 2010;
Accepted: January 24, 2011.
Published online: 2011 May 30.
PII: S09747559INPE1000081-2
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Abstract
We conducted this study to evaluate the adequacy
of breastmilk as a source of vitamin E in exclusively breastfed VLBW
infants. Such infants (n=44) were randomly allotted to
receive vitamin E supplementation (n = 23); the rest (n
= 21) did not receive vitamin E. After 21 days, the vitamin E level
in the supplemented group was 0.78 + 0.26 mg/dL as compared
to 0.77+ 0.25 mg/dL in the unsupplemented group (P=0.69).
The ratio of Vitamin E to lipids was also comparable in the two
groups, (P=0.65). We concluded that vitamin E supplementation
is not routinely needed in VLBW infants.
Key words: India, Breastmilk, Very low birth weight,
Vitamin E.
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P
remature infants, that constitute majority of very
low birth weight infant population, are born with disproportionately
lesser body stores of vitamin E than term infants [1]. Milk produced
during the early weeks post partum by mothers of preterm infants (preterm
milk) more closely approximates the nutritional requirement of preterm
infant than does mature human milk [2]. Breastmilk, especially colostrum,
is a very rich source of vitamin E. However, adequacy of breastmilk as a
sole source of vitamin E to premature infant is controversial and
supplementation of 5 IU has been recommended for low birth weight neonates
[3]. The present study aims at comparing vitamin E status of exclusively
breastfed preterm neonates with or without vitamin E supplementation.
Methods
Participants included 75 infants over a period of 1
year, admitted consecutively to the referral neonatal unit with following
inclusion criteria (i) weight less than 1500 grams; (ii)
gestational age less than 37 weeks; and (iii) mothers willing to
exclusively breastfeed the neonate. Infants admitted to referral neonatal
unit after 48 hours of life; those where enteral feed was withheld for
more than 6 consecutive days; and those having any major congenital
malformation or chromosomal anomaly, were excluded. The protocol of the
study was approved by the Institutional Ethical Committee. Sample size
calculations were not done as no similar studies in the past could be
identified. Infants enrolled in the study were randomized using computer
generated random number sequence and allocated numbers in the order in
which they got admitted in the neonatal unit. All infants, irrespective of
their groups, were exclusively given their own mothers milk. Expressed
breastmilk was fed by intermittent tube feeds 2 hourly till the infant
started suckling. Ryle’s tube feeds were started by a maximum volume of 24
mL/kg/day between 1 and 6 days of life. It was increased by 24 mL/kg/day
with the aim of attaining 180 mL/kg/day by day 8 of starting the enteral
feeds, as per protocol followed in the unit [4]. After attaining maximum
volume feeds by nasogastric tube, feeds were gradually replaced by
exclusive breastfeed every 2 hours. Infants received dextrose and
electrolytes intravenously until an enteral feed volume of 100 mL/kg/day
was achieved. Infants did not receive any other form of intravenous
nutrition. Infants randomized to Group 1 received vitamin E
supplementation in form of drops (Evion Pediatric drops, 50 mg/mL; 2 drops
once a day i.e. 5 IU/day), which was started as soon as the neonate
could tolerate certain amount of enteral feed (6-8 mL/kg body weight/feed)
through ryles tube. Group 2 infants served as controls. No placebo was
given. The infants were not put on iron supplementation during the study
period. A follow up of 21 days was chosen as it is the average time the
neonate is kept in the neonatal unit after which the infants are shifted
to the wards, and following stabilization are sent home. Blood samples of
2 mL were obtained from all study infants on day 21 of admission. It was
centrifuged, serum separated and stored at -20 ºC
in deep freeze till further analysis. Estimation of serum
a-tocopherol was
done using a fluorometric micromethod [5]. Estima-tion of serum
cholesterol and serum triglycerides was done using enzymatic method [6]
and enzymatic colorimetric GPO (glycerol phosphate oxidase) method [7],
respectively. Statistical comparison for means was done using student’s
t test, paired or unpaired as applicable. Excel Epi 6 stat and Epistat
(software packages) were used for analyzing the data.
Results
Out of 75 infants that entered the study, 30 expired
and one patient left against medical advice. A total of 44 babies could
complete the study and were followed up for a period of 21 days (Table
I).
TABLE I Characteristics of Study Population
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Group 1 (n=23) |
Group 2 (n=21) |
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(Supplemented) |
(Controls) |
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Age at admission (h) |
14.52 |
19.55 |
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Females |
10 |
10 |
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*Mean neonatal weight (g) |
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Day1 |
1283.6 ± 196.2 |
1310 ± 150.6 |
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Day 21 |
1334.5 ± 194.2 |
1401 ± 154.5 |
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*Mean gestational age (wk) |
31.5 ± 2.5 |
32.1 ± 2.6 |
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Gestational age <32 wks |
14 |
9 |
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* P<0.05 for
differen ce in two groups. |
Table II presents the biochemical status of the
two groups. Vitamin E levels in 39 out of 44 infants were more than
0.5 mg/dL, which is chosen for defining deficiency state [3], leaving only
5 infants with low values (3 from Group1 and 2 from Group 2). Both groups
were comparable with regards to vitamin E status at 21 days. These results
are applicable to neonates above 28 weeks gestation age and 900 grams body
weight.
TABLE II Biochemical Status of The Study Population
| Serum levels |
Group 1 |
Group 2 |
| Tocopherol (mg/dL) |
0.78 ± 0.26 |
0.77 ± 0.25 |
| Cholesterol (mg/dL) |
138.8 ± 44 |
133.9 ± 35 |
| Triglycerides (mg/dL) |
110.4 ± 51 |
104.4 ± 56 |
| Tocopherol/lipid ratio |
3.4 ± 1.6 |
3.3 ± 0.7 |
| Tocopherol/cholesterol ratio |
6.2 ± 3.8 |
6.2 ± 3.8 |
Discussion
Adequacy of breast milk as a wholesome nutrient in a
newborns diet is an established fact. Human milk content of tocopherol
ranges between 0.29-0.54 mg/dL [3]. In this study, all the mothers could
provide sufficient volume of milk and were able to breastfeed exclusively.
There is ample evidence of large quantities of tocopherol crossing mammary
barrier in colostrum and early breastmilk [8-10]. The supplemented and non
supplemented group of exclusively breast fed VLBW infants had adequate and
comparable vitamin E levels even with respect to lipids.
There were a few limitations in our study. No blinding
was done. A larger number of subjects would have been better, but due to
high mortality in referred VLBW infants, 30 subjects were excluded from
the study before randomization. Breastmilk vitamin E status was not
analyzed separately in mothers of preterm and term infants.
We conclude that breastmilk is an adequate source of
vitamin E for exclusively breast fed VLBW infants and vitamin E
supplementation during the first 3 weeks does not improve the vitamin E
status of the neonate. There is scope for a study with larger sample size
to further study the long term implication of vitamin E supplementation in
VLBW infants.
Contributors: ST: acquisition of data drafting the
article and analysis and interpretation of the data; TKM: substantial
contribution to the concept and design and final approval of the version
to be published; NBM: substantial contribution to the concept and design,
drafting the article, and revising it critically for important
intellectual content.
Funding: None.
Competing interests: None stated.
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What This Study Adds?
• Breastmilk is an adequate source of vitamin E in preterm very
low birth weight infants.
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