• The gastrointestinal (GI) tract of a normal fetus is sterile.
• The type of delivery has an effect on the development of the intestinal microbiota.

* Vaginally born infants are colonized with their mother’s bacteria.

* Cesarean born infants’ initial exposure is more likely to environmental microbes from the air, other infants, and the nursing staff which serves as vectors for transfer.

• Babies at highest risk of colonization by undesirable microbes or when transfer from maternal sources cannot occur are cesarean-delivered babies, preterm infants, full term infants requiring intensive care, or infants separated from their mother.
• Breastfed and formula-fed infants have different gut flora.

* Breastfed babies have a lower gut pH (acidic environment) of approximately 5.1-5.4 throughout the first six weeks that is dominated by bifidobacteria with reduced pathogenic (disease-causing) microbes such as E coli, bacteroides, clostridia, and streptococci o babies fed formula have a high gut pH of approximately 5.9-7.3 with a

variety of putrefactive bacterial species.

* In infants fed breast milk and formula supplements the mean pH is approximately 5.7-6.0 during the first four weeks, falling to 5.45 by the sixth week.

* When formula supplements are given to breastfed babies during the first seven days of life, the production of a strongly acidic environment is delayed and its full potential may never be reached.

* Breastfed infants who receive supplements develop gut flora and behavior like formula-fed infants.

• The neonatal GI tract undergoes rapid growth and maturational change following birth.

* Infants have a functionally immature and immuno-naive gut at birth.

* Tight junctions of the GI mucosa take many weeks to mature and close the gut to whole proteins and pathogens.

* Open junctions and immaturity play a role in the acquisition of NEC, diarrheal disease, and allergy.

* sIgA from colostrum and breast milk coats the gut, passively providing immunity during the time of reduced neonatal gut immune function.

* Mothers’ sIgA is antigen specific. The antibodies are targeted against pathogens in the baby’s immediate surroundings.

* The mother synthesizes antibodies when she ingests, inhales, or otherwise comes in contact with a disease-causing microbe.

* These antibodies ignore useful bacteria normally found in the gut and ward off disease without causing inflammation.

• Infant formula should not be given to a breastfed baby before gut closure occurs.

* Once dietary supplementation begins, the bacterial profile of breastfed infants resembles that of formula-fed infants in which bifidobacteria are no longer dominant and the development of obligate anaerobic bacterial populations occurs. (Mackie, Sghir, Gaskins, 1999)

* Relatively small amounts of formula supplementation of breastfed infants (one supplement per 24 hours) will result in shifts from a breastfed to a formula-fed gut flora pattern. (Bullen, Tearle, Stewart, 1977)

* The introduction of solid food to the breastfed infant causes a major perturbation in the gut ecosystem, with a rapid rise in the number of enterobacteria and enterococci, followed by a progressive colonization by bacteroides, clostridia, and anaerobic streptococci. (Stark & Lee, 1982)

* With the introduction of supplementary formula, the gut flora in a breastfed baby becomes almost indistinguishable from normal adult flora within 24 hours. (Gerstley, Howell, Nagel, 1932)

* If breast milk were again given exclusively, it would take 2-4 weeks for the intestinal environment to return again to a state favoring the grampositive flora. (Brown & Bosworth, 1922; Gerstley, Howell, Nagel, 1932)

• In susceptible families, breastfed babies can be sensitized to cow’s milk protein by the giving of just one bottle, (inadvertent supplementation, unnecessary supplementation, or planned supplements), in the newborn nursery during the first

  three days of life. (Host, Husby, Osterballe, 1988; Host, 1991)

* Infants at high risk of developing atopic disease has been calculated at 37% if one parent has atopic disease, 62-85% if both parents are affected and dependant on whether the parents have similar or dissimilar clinical disease, and those infants showing elevated levels of IgE in cord blood irrespective of family history. (Chandra, 2000)

* In breastfed infants at risk, hypoallergenic formulas can be used to supplement breastfeeding; solid foods should not be introduced until 6 months of age, dairy products delayed until 1 year of age, and the mother should consider eliminating peanuts, tree nuts, cow’s milk, eggs, and fish from her diet. (AAP, 2000)

• In susceptible families, early exposure to cow’s milk proteins can increase the risk of the infant or child developing insulin dependent diabetes mellitus. (IDDM) (Mayer et al, 1988; Karjalainen, et al, 1992)

* The avoidance of cow’s milk protein for the first several months of life may reduce the later development of IDDM or delay its onset in susceptible individuals. (AAP, 1994)

* Sensitization and development of immune memory to cow’s milk protein is the initial step in the etiology of IDDM. (Kostraba, et al, 1993)

• Sensitization can occur with very early exposure to cow’s milk before gut cellular tight junction closure.
• Sensitization can occur with exposure to cow’s milk during an infection-caused gastrointestinal alteration when the mucosal barrier is compromised allowing antigens to cross and initiate immune reactions.
• Sensitization can occur if the presence of cow’s milk protein in the gut damages the mucosal barrier, inflames the gut, destroys binding components of cellular junctions, or other early insult with cow’s milk protein leads to sensitization. (Savilahti, et al, 1993)

References

American Academy of Pediatrics, Work Group on Cow’s Milk Protein and Diabetes Mellitus. Infant feeding practices and their possible relationship to the etiology of diabetes mellitus.  Pediatrics 1994; 94:752-754

American Academy of Pediatrics, Committee on Nutrition. Hypoallergenic infant formulas. Pediatrics 2000; 106:346-349

Brown EW, Bosworth AW. Studies of infant feeding VI. A bacteriological study of the feces and the food of normal babies receiving breast milk. Am J Dis Child 1922; 23:243

Bullen CL, Tearle PV, Stewart MG. The effect of humanized milks and supplemented breast feeding on the faecal flora of infants. J Med Microbiol 1977; 10:403-413

Chandra RK. Food allergy and nutrition in early life: implications for later health. Proc Nutr Soc 2000; 59:273-277

Gerstley JR, Howell KM, Nagel BR. Some factors influencing the fecal flora of infants. Am J Dis Child 1932; 43:555

Host A, Husby S, Osterballe O. A prospective study of cow’s milk allergy in exclusively breastfed infants. Acta Paediatr Scand 1988; 77:663-670

Host A. Importance of the first meal on the development of cow’s milk allergy and intolerance. Allergy Proc 1991; 10:227-232

Karjalainen J, Martin JM, Knip M, et al. A bovine albumin peptide as a possible trigger of

insulin-dependent diabetes mellitus. N Engl J Med 1992; 327:302-307

Kostraba JN, Cruickshanks KJ, Lawler-Heavner J, et al. Early exposure to cow’s milk and solid foods in infancy, genetic predisposition, and risk of IDDM. Diabetes 1993; 42:288-295

Mackie RI, Sghir A, Gaskins HR. Developmental microbial ecology of the neonatal

gastrointestinal tract. Am J Clin Nutr 1999; 69(Suppl):1035S-1045S

Mayer EJ, Hamman RF, Gay EC, et al. Reduced risk of IDDM among breastfed children. The Colorado IDDM Registry. Diabetes 1988; 37:1625-1632

Savilahti E, Tuomilehto J, Saukkonen TT, et al. Increased levels of cow’s milk and blactoglobulin antibodies in young children with newly diagnosed IDDM. Diabetes Care 1993; 16:984-989

Stark PL, Lee A. The microbial ecology of the large bowel of breastfed and formula-fed infants during the first year of life. J Med Microbiol 1982; 15:189-203

Occasionally they may need extra oxygen by tube, nasal prongs or even need a respirator. Intravenous calories can nourish and sustain the most vulnerable preemies and a gradual transition from tube feeding to breast or bottle will let the stomach and intestines mature without risking harm.

Even babies born a week or two early can have “respiratory distress syndrome of prematurity”–or RDS as it’s called–but this is much more likely under 34-35 weeks gestation (5-6 weeks early.) If premature delivery is anticipated and can’t be stopped, an obstetrician will give the mother-to-be an injection of steroids to speed up lung maturation. This relatively simple and apparently harmless medication has saved countless babies’ lives and kept others from prolonged hospitalizations. Your doctor may not have a lot of time to explain this fully to you when it’s needed on an emergency basis but please know that it works and is safe.

Below I answer frequently-asked questions about the impact of prematurity on infant survival, development, vaccination decisions, and family dynamics.

Q: My sister-in-law delivered 5 weeks early. She smokes, and I’ve heard that smoking can trigger early labor. Is that true? What are my chances of having a premature baby?

A: Yes, smoking and poor (or absent) prenatal care increase the risk of prematurity. Low maternal weight, poor nutrition, drug abuse, maternal age under eighteen years or over forty may lead to prematurity. An attentive doctor in partnership with a healthy aware mom-to-be should recognize many of the risk factors and then the signs of pre-term labor. Premature labor can often be stopped with decreased activity, bed rest and medication. Please make sure you discuss these signs and symptoms with your doctor in early pregnancy visits.

Anatomical problems such as an incompetent cervix, fibroid tumors and unusual uterine shape may predispose a woman to early labor and delivery, too.

Q. “My friend’s baby has been diagnosed with cerebral palsy. He was born 8 weeks early, was in the hospital for over six weeks and had quite a few complications during that hospitalization. Is cerebral palsy associated with prematurity?”

A. Babies with neurological abnormalities or physical anomalies may be born early. We’re not quite sure why.

We’re also not sure if “cerebral palsy” (a broad diagnosis which encompasses motor and intellectual problems of infancy, childhood and beyond) is the cause of the premature birth. The other possibility is that babies who go through hard deliveries and then require extra oxygen, develop infections and have rocky hospital course suffer some injury to the nervous system and develop the neurological problems which we call cerebral palsy.

This is a medical and a medicolegal issue and an extremely difficult discussion with your doctor. The prognosis for recovery is tremendously varied and I have seen many babies who looked pretty bad at the beginning make great recoveries as the months and years go by. I have become certain that optimism is almost always warranted.

Here’s the hardest part: Very few people have spent much time in a Newborn Intensive Care Unit. Here is what you will see: The premature infant will have at least one and sometimes as many as three IV lines. One or two may originate from the belly button where the umbilical blood vessels provide the best access for fluids and medicine. Extra oxygen may be delivered with a hood, mask, nasal prongs or through an endotracheal tube from a respirator. A preemie can look much more fragile and much sicker than he actually is and the first reaction may be panic and fear. Make certain that everything, absolutely everything, is explained to you during those first hours and that re-explanations and updates are given frequently.

Babies born prematurely or with any problems or instability are a completely different issue and you’ll be happy you’ve chosen an OB you trust, a pediatrician attentive to your baby and a hospital which can handle the problems or prematurity.

But, most babies are born at or near term (37-41 weeks) and need no extra attention from the nursery and don’t need to be separated from their moms and dads. Talk to your doctors and the nursery about this before you go into labor. It’s a much tougher discussion at 6 or 7 centimeters dilation.

Vitamin K is a slightly controversial topic. I believe it should be given orally rather than by injection, but most doctors and other expert disagree and have good reasons for their position. Discuss this with your doctor and read a little about the topic.

Previously silver nitrate and now erythromycin or tetracycline is used in newborns’ eyes to prevent the transmission of gonorrhea and chlamydia. Research published in mainstream journals has repeatedly stated that choosing no eye care at all is a reasonable option. Again, most experts disagree, but the research is clear and I recommend no eye care at all for babies who have responsible parents, good prenatal care and pediatric follow up. I have a more extensive article on this subject here: Neonatal Eye Care

Rooming in and not sending your baby to the nursery at all is accepted practice in many if not most hospitals. Again, almost all of this advice is applicable to healthy full term babies only.

Leave the hospital as early as you can but secure good follow-up for the first few days of life. Either a three day doctor visit or, preferably, a home visit from a lactation consultant to make sure that breastfeeding goes well in the first days and weeks. Get the help you need.