In 1994 the American Academy of Pediatrics recommended more liberal rules for the treatment of hyperbilirubinemia in healthy term newborns. Yet, the safety of moderate degrees of hyperbilirubinemia in healthy term newborns is debated. To evaluate the safety of moderate degrees of hyperbilirubinemia, we assessed neurologic condition of 20 healthy nonhemolytic term newborns with peak total serum bilirubin levels of 233-444 mol/L and 20 control infants matched for sex and gestational age at birth. Neurologic condition was evaluated with techniques focusing on the presence of minor neurologic dysfunction: in the newborn period according to Prechtl, at 3 mo on the basis of the quality of general movements, and at 12 mo according to Touwen. Moderate hyperbilirubinemia turned out to be associated with a significant increase in minor neurologic dysfunction throughout the first year of life. At 12 mo a strong dose-response relationship between the degree of hyperbilirubinemia and the severity of minor neurologic dysfunction was present. Our results indicate that total serum bilirubin levels 335 mol/L should be avoided. In 1994 the American Academy of Pediatrics recommended new guidelines for the treatment of hyperbilirubinemia in healthy term newborns without hemolytic disease (1). Before 1994 treatment was started generally when total serum bilirubin levels exceeded 239 -257 mol/L (14 -15 mg/dL) (2). According to the new, more liberal guidelines it is acceptable to postpone in infants aged at least 72 h the onset of treatment until the total serum bilirubin level exceeds 340 mol/L. The new recommendations were also implemented in clinical practice in the Netherlands (3).The rationale for the new recommendations was that therapeutic interventions for hyperbilirubinemia in healthy term infants may carry significant risk relative to the uncertain risk of hyperbilirubinemia in this population. The uncertain risk was considered to be relatively low. This point of view was supported by the review of Newman and Maisels, which concluded that bilirubin levels below 340 mol/L did not have a significantly adverse effect on neurologic, mental (IQ) and hearing development (4). Yet, at present it is not clear whether moderate degrees of hyperbilirubinemia (205-340 mol/L) (2) in term infants do not result in an increased risk for so-called minor developmental disorders, such as clumsiness and attention deficit hyperactivity disorder. In this respect it is good to realize that the term minor in minor developmental disorders is more related to the degree of dysfunction of the neural substrate than to its clinical impact, as minor developmental disorders often strongly interfere with the child's activities of daily life (5, 6). In fact, the data of the American Collaborative Perinatal Project, in which a large number of children born in the sixties were followed extensively, suggest that moderate degrees of hyperbilirubinemia are associated with an increased risk of minor motor problems at school-age (7).The aim of the present study is t...

We conclude that parameters of early neonatal AA status are related to intra-uterine rather than to post-natal growth. Parameters of post-natal brain growth are related to RBC DHA and CE DHA contents on day 42, and to dietary protein intake. These results point to the importance of dietary DHA for brain growth in the first 6 post-natal weeks.

We investigated whether a regular formula for premature infants (pre) supplemented with ribonucleotides (pre+RN) raises erythrocyte and plasma cholesterol ester (CE) long-chain polyunsaturated fatty acids (LCPUFAs) of low-birth-weight babies (< or = 2.50 kg) compared with their breast-fed counterparts. From days 11 to 42, 31 babies received the pre formula and 37 received pre+RN. Eleven breast-fed babies served as a reference group. Erythrocytes and CE fatty acids were determined on days 11, 21, and 42. There were no differences in the courses of erythrocytes and CE fatty acids between pre formula-fed and pre+RN-fed babies. On day 42, formula-fed babies had lower erythrocytes and CE n-3 and n-6 LCPUFAs compared with breast-fed babies. Subdivision into gestational age- and body weight-matched subgroups gave similar results. RN supplementation does not augment the erythrocyte and CE LCPUFA status of formula-fed babies.

It has remained unclear whether the amount of fecal fat excreted in the stool and stool production influences the severity of neonatal jaundice. We determined the relationship between stool production, fecal fat excretion and jaundice in healthy breast-fed (BF) or formula-fed (FF) (near-)term neonates. From postnatal day 1-4, we quantitatively collected stools from 27 FF and 33 BF infants in daily fractions. Stool production and fecal fat contents were related to unconjugated bilirubin (UCB) levels, as determined by transcutaneous bilirubinometry (TcB). Bilirubin concentrations and stool production did not differ between FF and BF neonates during the study period. Neonatal bilirubin levels were not inversely correlated with stool production. FF and BF infants had similar fecal fat excretion rates. The stool production of FF infants was profoundly lower in the present study than in a 1985 study by De Carvalho et al. [J Pediatr (1985) 107:786-790]. We conclude that increased jaundice during the first postnatal days in healthy term neonates can no longer be attributed to breast-feeding and speculate that improved absorbability of formulas since 1985 has contributed to similar fat excretion and stool production in FF and BF neonates in 2007.

Sir: Long-chain polyunsaturated fatty acids (LCPUFA) are important for the development of the CNS, including the retina [2]. Breast milk contains a large range of LCPUFAs, including docosahexaenoic (22:633, DHA) and arachidonic (20:436, AA) acids, whereas most formula milks for term infants do not. Newborns do not seem to synthesize sucient amounts from their precursors to cover their high needs resulting in a lower DHA and AA status of formula-fed children compared to their breast-fed counterparts. For establishment of the LCPUFA status, most investigators measure their contents in erythrocytes (RBCs), which are regarded as reliable markers for brain LCPUFA content. Since low postnatal DHA status has been related to impaired visual acuity and cognitive development [2], concern has risen about brain development of formula-fed term and, particularly, preterm infants. As a consequence, most preterm formulas in Europe are at present supplemented with LCPUFA, notably DHA or a combination of AA and DHA. Low RBC LCPUFAs have also been observed in malnourished children, many of them receiving breast milk and weaning food low in fat [4]. In these children, it has been postulated that the synthesis of LCPUFA from their precursors is decreased [1], making them more dependent on an adequate LCPUFA intake.Over the last few years we have been evaluating the LCPUFA status of various groups of infants and adults with dierent dietary patterns and nutritional conditions by establishing their RBC LCPUFA levels. These subjects comprised: low birth weight infants (age 1.5 months), who received either breast milk or a formula without LCPUFA [5, part of the data]; healthy 3.5-year-old children and adults (age 22±61 years) in The Netherlands (unpublished data); healthy, breast-fed infants in Jerusalem (age 1±6 months) (unpublished data); and well nourished and malnourished children in North Pakistan (age 2±60 months), either breast fed or not [4]. In these studies we made use of the same sampling techniques, prepuri®cation methods and analyses by capillary gas chromatography with¯ame ionization detection. Comparison of the outcomes of RBC DHA levels (Table 1) revealed large dierences between the groups. Well nourished breast-fed Jerusalem infants exhibited the highest RBC DHA levels. Malnourished, not breast-fed, Pakistani children had the lowest levels, 75% having RBC DHA levels below the 95% con®dence interval of the formula-fed Dutch infants! These dierences do not seem to be due to imperfect age matching, since apparently healthy Dutch adults do not exhibit much dierence in RBC DHA content compared with 42 day-old Dutch low birth weight infants. Although malnourished breast-fed Pakistani children had a better DHA status than those receiving no human milk, their levels were much lower compared to breast-fed infants from The Netherlands and Jerusalem and, surprisingly, 27% of them had RBC DHA levels below the 95% con®dence interval of the formula-fed Dutch infants. Since the fatty acid composition of human milk is strongly dependent ...

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