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In preterm infants, the goal of aggressive extrauterine nutritional management is to mimic in utero growth and nutrient accretion. Over the latter half of the 20th century, nutritional optimization through the practice of fortifying human milk rose to practice with increased survival rates in preterm infants of younger gestational age. The quest for optimal preterm fortification and nutrition remains a contentious area of debate. This review aims to summarize the historical perspectives of human milk fortification as well as the current literature advocating for the use of liquid human milk fortifiers in enterally fed premature infants.

OBJECTIVE: Compare effectiveness of maternal vitamin D3 supplementation with 6400 IU per day alone to maternal and infant supplementation with 400 IU per day. METHODS: Exclusively lactating women living in Charleston, SC, or Rochester, NY, at 4 to 6 weeks postpartum were randomized to either 400, 2400, or 6400 IU vitamin D3/day for 6 months. Breastfeeding infants in 400 IU group received oral 400 IU vitamin D3/day; infants in 2400 and 6400 IU groups received 0 IU/day (placebo). Vitamin D deficiency was defined as 25-hydroxy-vitamin D (25(OH)D) RESULTS: Of the 334 mother-infant pairs in 400 IU and 6400 IU groups at enrollment, 216 (64.7%) were still breastfeeding at visit 1; 148 (44.3%) continued full breastfeeding to 4 months and 95 (28.4%) to 7 months. Vitamin D deficiency in breastfeeding infants was greatly affected by race. Compared with 400 IU vitamin D3 per day, 6400 IU/day safely and significantly increased maternal vitamin D and 25(OH)D from baseline (P < .0001). Compared with breastfeeding infant 25(OH)D in the 400 IU group receiving supplement, infants in the 6400 IU group whose mothers only received supplement did not differ. CONCLUSIONS: Maternal vitamin D supplementation with 6400 IU/day safely supplies breast milk with adequate vitamin D to satisfy her nursing infant’s requirement and offers an alternate strategy to direct infant supplementation.

The 2008 revised American Academy of Pediatrics (AAP) recommendation for 400 IU/day vitamin D intake makes progress toward achieving infant vitamin D sufficiency in the United States. Further study, however, is needed both to define vitamin D sufficiency for preterm infants based on markers of vitamin D biologic function and to develop supplementation strategies to ensure adequate vitamin D intake and, thus, vitamin D sufficiency in this at-risk population. In this review, we highlight some of the issues surrounding vitamin D status of the neonate and the particular risks for the preterm infant. We review the evidence regarding the impact of vitamin D deficiency in this population and the safety and efficacy of vitamin D supplementation. Based on previous study in preterm infants, the current AAP guidelines to achieve serum 25-hydroxyvitamin D [25(OH)D] status of at least 50 nmol/L and to receive at least 400 IU/day are safe and possibly adequate. Because of the nutritional difficulties in achieving consistent delivery of 400 IU/day of vitamin D in the preterm infant, it is imperative to devise strategies for close monitoring of each preterm infant's vitamin D status and consider oral vitamin D supplementation as an important adjunct to dietary sources and multivitamin preparations.

Objective. The 88% saturation test (88%-SAT) was developed as an alternative to standard spirometry for those young children unable to perform standard forced expiratory maneuvers. In adults, this test revealed rapid desaturation in those persons with a history of asthma when compared with healthy control subjects. Similar findings in children were tested. Setting. Tertiary care hospital. Patients. Thirty-three former premature infants (28.3 ± 2.3 weeks gestation), aged 5 to 7 years, who were participating in a follow-up study, were enrolled in this study. Design. The study compared the 88%-SAT with standard spirometry and respiratory health characteristics ascertained through a parental questionnaire. The 88%-SAT consists of continuous measurement of hemoglobin saturation by pulse oximetry (Sao2) while the subject breathes a nonhumidified 12% oxygen and nitrogen mixture for 10 minutes or until Sao2 decreases to 88%, whichever occurs first. Abnormal 88%-SAT was defined as a decrease of Sao2 to 88% within the 10-minute period, and abnormal spirometry was defined using standardized values. Results. Of the 20 children who successfully completed both spirometry and the 88%-SAT, 10 had normal spirometry results and did not desaturate to 88%, and 5 had abnormal spirometry and 88%-SAT results. Four children did not desaturate during the 88%-SAT, but had abnormal spirometry results, and one child had abnormal 88%-SAT results, but normal spirometry. Ten additional children completed the 88%-SAT, but not standard spirometry. Three children were unable to complete either test. Of those 30 children tested, 7 (23%) had a history of reactive airways disease, and all 7 had abnormal 88%-SAT results. The 88%-SAT had greater sensitivity (100% vs 75%) and specificity (87% vs 63%) than spirometry in identifying children with known reactive airways disease. The mean McCarthy general cognitive index (GCI) of the group performing both spirometry and the 88%-SAT (n = 20) achieved a mean (± SD) GCI of 96.2 ± 16.7, and the group (n = 30) that completed the 88%-SAT had a mean (± SD) GCI of 75.2 ± 26.3 (χ2 P < .012). The 10 children able to perform only the 88%-SAT had a mean GCI (± SD) of 72.8 ± 26.9, and the 3 children unable to perform either test had a mean GCI (± SD) of 63 ± 11. Conclusions. Our data suggest that the 88%-SAT may be more effective than spirometry for identifying reactive airways disease in young, uncooperative, or developmentally delayed children. The dry air of the hypoxic inspired gas may function as an airway challenge, leading to decreased oxygenation in patients with reactive airways.