Presentation for immunonutrition in neonate

1. Immunonutrition in Neonate
Dr. Rabi Dhakal

2. Introduction
• Nutrition and infections are intimately related, which is particularly
important for young children.
• A functional immune system is essential for survival, but an
appropriate balance between the pro-inflammatory and anti-
inflammatory responses must be maintained.
• An important part of nutrition and health is immuno-nutrition, which
can be defined as the effect of the provision of specific nutrients on
immune function.
• Administered via enteral or parenteral routes.

3. IMMUNE RESPONSE TO CRITICAL ILLNESS
Immune response
SIRS
Inhospitable for pathogens Multiorgan dysfunction
Compensatory anti-inflammatory response syndrome(CARS)
Immune system is affected by baseline nutritional status and can be modulated by macro and micronutrients.

5. Antioxidant vitamins and trace elements
• Antioxidant defense system includes enzymes (superoxide dismutase,
glutathione peroxidase), trace elements (Se, Zn), vitamins and
glutathione.
• Critical illness is associated with deficits in antioxidants due to
• Redistribution from blood to tissues
• Increased losses
• Decreased nutritional intake

6. • Low antioxidant levels are linked with immune dysfunction, higher
infection rates and increased morbidity and mortality during critical
illness.
• Antioxidants catalyze breakdown of ROS

7. Rationale for immunonutrition
• Transient down-regulation adaptive immunity
• Prevent downstream damage organs
• Leukocyte apoptosis and deactivation
• Limit inflammatory response and organ damage

8. • Three potential targets exist for immuno-nutrition-mucosal barrier
function, cellular defense, and local or systemic inflammation.
• Role players:
Micronutrients: Selenium, zinc.
Macronutrients: Amino acids and omega-3 fatty acids.
Probiotics .

9. Zinc
• Zinc is an essential trace element that is required for normal growth
and development, neurocognitive function, glucose homeostasis,
response to oxidative stress, and immune function.
• Zinc deficiency results in impaired immune function.
This leads to impaired killing of parasites, viruses, and bacteria.

10. Dosing and toxicity of zinc supplementation
• Standard parenteral dosing of zinc under normal circumstances is 200
mcg/kg per day.
• Orally - 1 to 2 mg elemental Zinc/kg/day.
• Toxicity with PN supplementation has been reported only with very
large unintentional ingestions, manifested by fever, anemia, and
pancreatitis.

11. Selenium
• It is a constituent of the antioxidant enzyme-Glutathione perxidase
and therefore is vital to antioxidant defense.
• Several diseases of the neonate have been shown to be caused at
least in part by oxygen free radicals. These include bronchopulmonary
dysplasia ,retinopathy of prematurity,necrotising enterocoltics,patient
ductus arteriosus and neuronal injury of hypoxic ischemic
encephalopathy.
• Good selenium nutrition is therefore of key importance to antioxidant
defense in the neonate.
• The recommended selenium intake neonate is 1.3-3 µg/kg/day.

12. Glutamine
Glutamine is most abundant free amino acid in the body.

13. Dosing of glutamine
• Infusions of GLN at doses up to 0.48 g/kg per day have been well
tolerated in infants without any apparent complications.

14. Arginine
• Arginine is an essential amino acid in the fetus and Neonate.
• It had been shown that premature infants who subsequently developed NEC
had a significant lower plasma concentration of arginine than did infants
who did not develop NEC
Recommendations for supplementing critically
ill children with arginine cannot be made, and
further studies are needed.

16. Nucleotides
• Nucleotides, nucleosides and nucleobases belong to the non-protein-
nitrogen fraction of milk.
• Nucleotide supplementation could enhance the rate of cell
proliferation and differentiation as well as spare the need for
glutamine during enterocyte growth and development.

17. • Supplemental nucleotides have been shown to be helpful in
enhancing antibody responses, helping in the repair of damaged gut
mucosa, contributing to iron absorption in the gut and influencing
long-chain polyunsaturated fatty acid (PUFA) synthesis in early life .

18. Omega-3 polyunsaturated fatty acids (PUFA)
• Dietary fatty acids such as linoleic acid and α-linolenic acid
respectively, are considered ‘‘essential’’ because they must be derived
from the diet.
• Modulation of immune and inflamatory responses has been reported
with increased intakes of PUFA.

19. • PUFA supplementation(AA/DHA ratio of 1.5:1)
significantly reduced the incidence of NEC in the
neonatal rat model by downregulating platelet-
activating factor (PAF) production, PAF receptor
synthesis, and endotoxin translocation into the
systemic circulation.

20. Probiotics and prebiotics
• Probiotics are defined as live microbial food supplements that
beneficially affect the host animal by improving its intestinal microbial
balance.
• Lactobacillus and Bifidobacterium

21. • Prebiotics are simple, naturally occurring or synthetic sugars that are
used by certain colonic bacteria, especially bifidobacteria, as a carbon
source for growth and metabolism.
• Inulin, fructooligosaccharides, galacto-oligosaccharides, and lactulose.
• Subjects receiving 15 g fructo-oligosaccharides or inulin per day had
higher Fecal bifidobacterial counts increased almost 10-fold, whereas
those of bacteroids, coliforms, and cocci decreased.

22. • Probiotics need to be administered frequently to
obtain maximal effect, the combined use of pre and
probiotics might offer advantages over the
administration of probiotics alone.

23. Lactoferrin
• Lactoferrin (LF), an iron-binding protein, is the most abundant whey
protein in human milk.
• LF has been reported to have bacteriostatic, bactericidal, antifungal
and antiviral effects. Because iron is an essential growth factor for
most microorganisms, the low degree of iron saturation of LF in
human milk and high affinity for iron suggests that LF is a
bacteriostatic agent that inhibits the growth of bacteria.

24. Summary
1. A functioning immune system is essential for survival, and
an appropriate balance between the pro-inflammatory and
anti-inflammatory response must be maintained.
2. The provision of specific nutrients to manipulate the
immune system- immunonutrition.
3. The components of the immune system can be modulated
by certain macronutrients (GLN, arginine, and omega-3
fatty acids) and micronutrients (Se, zinc, and).

25. Thank you