Evaluation of the Antioxidant Activity of Lutein/Zeaxanthin Early Administered to Premature Newborns
Phase: NA
Conditions: Antioxidant Role of the Lutein in Preterm Newborn
Sponsor: Sooft Italia

TITLE OF FORM:  
 
“Evaluation of the antioxidant activity of lutein/zeaxanthin early 
administered to premature newborns” 
 
 
 
Date: 09/06/2017 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 1 
Translation from Romanian 
 
 
 
Evaluation of the antioxidant activity of lutein/zeaxanthin early 
administered to premature newborns 
 
TYPE OF STUDY: PILOT STUDY OF 50 (25 CASES + 25 CONTROLS) 
SUBJECTS RECRUITED 
 
AORN  Santobono-Pausilipon Napoli (center national project coordinator) 
 
AOU  Siena (coordinating center of doses of biomarkers of oxidative stress) 
 
AOU Padova (center shared enrollment) 
 
 
 
 
 
 
 
 
 
Coordinating Doctor: 
 
 
 
 
Dr. Giuseppe De Bernardo: principal investigator 
 
Prof. Giuseppe Buonocore: Coordinator of the gathering and dispensing samples 
 
Dr. Daniele Trevisanuto: Coordinator of the collection cases 
 
 
Dr. Mariangela Longini: Laboratory Coordinator 
 
 
 
Title of study 
“Evaluation of the antioxidant activity of lutein/zeaxanthin early 
administered to premature newborns” 
Study Justification During late years, there were many studies proving that lutein, a nutrient which is 
part of the carotenoids family, can be a real and important factor in preventing 
and protecting against numerous chronical diseases that affect millions of people 
in the entire world (such as in diabetic retinopathy in adult). The specialized 
literature, richer in information, is the one containing scientific studies and 
demonstrations which highlight and confirm the fact that lutein is able to reduce 
or slow down the risk of appearance of an ophthalmic pathology.   
Lutein is a polar soluble hydroxylate deriving from xantophylls that belong to the 
caroteniods family. The carotenoids are linear polyenes, i.e. hydrocarbons with 
conjugated double bonds, containing 40 atoms of charbon representing the 
highest class of phytochemical substances present in fruits, vegetables, human 
serum, breast milk, as well as human tissues.  
Carotenoids and their metabolites were largely studied in human serum and 
highlighted the physical and chemical characteristics through sophisticated 

 2 
methods (HPLC, magnetic resonance spectroscopy, mass spectrometry, UV 
spectrophotometry, etc.). Through these studies there were identified until present 
time, 27 carotenoids and 8 metabolites in the human body. Generaly, known 
carotenoids ingested, absorbed and metabolized by humans and found in serum 
are in number of 35. Lutein is the most important carotenoid present selectively in 
certain tissues of the human body, mainly at the level of the retina, macula (hence 
the name) and lens. In tissues and serum it is found together with a carotenoid 
dihydroxide, it isomer, zeaxanthin.   
Lutein, usualy ingested with other nutrients is partly eliminated directly through 
fecal matters (50-90%) and partially absorbed with the help of food fats. 
Incorporated in chylomicrons, it enters the blood flow where thanks to its 
liposolubility, it ties to the lipoprotein molecules (preferable HDL) and so it gets 
to different organs: liver, breast, colon, cervix, and ocularly, to the lens, iris and 
retina where, it selectively focuses in its central region (macula). In the cell, it is 
places in the entire thickness, from the exterior to the interior, in cellular 
membranes, tiding up to its polar terminal groups by its own membranes.  
Lutein and zeaxanthin are present at the level of the umbilical cord and pass 
through the placental barrier; they are also present in the plasmatic ones, in breast 
milk and especially in the colostrum. 
Concerning the way of administrating it, the lutein presents, through its specific 
characteristics, an elevated bioavailability after oral administration. The hematic 
levels of lutein, after providing nutriments rich in carotenoids, are increased with 
67% from the 14% observed at beta-caroten.  
Published studies proved that the chrono-active form of carotenoids is able to 
determin a slow release in the intestine offering a better absorption and reducinf 
the necessity to be assimilated together with food.  
Through interdisciplinary and coordinated studies, performed both in vitro and in 
vivo, there were identified different action mechanisms; particularly, it was 
demonstrated a defense mechanism of the tissue function by lutein, which is 
produced through the neutralization (quench) phenomenon of singlet oxygen and 
reactive oxygen species (ROS). This action provides the molecule with different 
activities: an antioxidant function, anti-inflammatory properties, properties which 
promote anti-tumoral effects, induction of detoxification enzymes and positive 
effect on proteins promoting the communication between joints (up-regulation).  
Recently, there have appeared experimental and chemical data proving that the 
oxidative stress and harmful actions determined by ROS can play an important 
role in the pathogenesis of many neurological diseases as Alzheimer, Parkinson in 
adult and ROP and NEC in newborns. 
This is due to the fact that the nervous system is characterized by membranes high 
in polyunsaturated fats, the first cellular compounds affected by ROS attack being 
the lipid perioxidation.  
A similar mechanism can appear to certain ocular tissues (macula, lens, retina) 
which, containing high amounts of polyunsaturated fat acids, are more vulnerable 
than other structures with oxidative degradations induced by ROS. 
Due to the fact that carotenoids are amongst the most powerful antioxidants 
existing in nature, there are being developed new researches concerning the 
functional role of these substances in preventing neurodegenerative diseases in 
newborns. For the first time, few researchers have managed to prove that lutein 
and zeaxanthin have a protecting role against the photostress of the human 
macula. This demonstration was possible by isolation, identifying the chemical 
structure and measuring the concentration of lutein and zeaxanthin and their 
oxidation products from the eyes of the donners.  

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During the pregnancy, the percentage of fat acids of pregnant women’s plasma 
increases with approximately 51%. The increase refers manly to the concentration 
of saturated (+ 57%) and monounsaturated (+ 65 %) fat acids, but also 
polyunsaturated fat acids increase significantly.  
Because thse polyunsaturated fat acids are very sensitive to oxidation, the 
modification of their plasmatic levels influences the state of the antioxidant 
systems on the mother and subsequently to the fetus. Many studies have proved 
that the increase of the susceptibility to the peroxidation of polyunsatured fat 
acids on pregnant women is accompanied by an equivalent increase of the 
tocopherol plasmatic concentrations which, immediately after birth, decrease 
sharply.   
The plasmatic concentrations of antioxidants on newborns, comparative to the 
mother’s were smaller. In the umbilical cord, the levels of tocopherols and 
carotenoids are significantly smaller that the ones registered in the maternal 
plasma and the concentration of polyunsaturated fat acids on the newborn is 
significantly higher and a lot more increased than on the mother.  
Furthermore, specific studies showed a growing interest towords the oxidative 
stress and oxygen reactive species which supposedly accumulate after birth. 
Many practices usualy used in the delivery room, for example the drugs given to 
pregnant woman to ease her pain, the newborn’s extraction methods, the 
techniques to minimize body temperature decrease, blocking the umbilical cord 
and especially the use of oxygen to 100 % or a ventilated room (Room Air, RA) 
for newborns presenting asphyxia signs, do not always prove to be efficient, but 
they can also compromise the health of the newborn as a result of a significant 
increase of free radicals.  
Some specific studies have compared the levels of free radicals, highlighted with 
particular markers, in the plasma of the umbilical cord of newborns with asphyxia 
treated 100% with oxygen or 21% with oxygen, comparative to a control group of 
children without asphyxia. The levels of free radicals were significantly increased 
immediately after birth in all three groups and grew at the two groups of 
newborns with asphyxia. In the group treated 21% with oxygen, these values 
decreased and at 28 days after birth, they have reached the same level of the 
newborns without asphyxia, whereas at the group treated 100% with oxygen the 
levels of free radicals still remains very high.  
Thus, it results that a short exposure of the newborn to 100% oxygen is the cause 
of an extended oxidative stress state and a consistent increase of free radicals 
which seem to be involved in different diseases and pathologies during the first 
months of life, especially in the preterm infant increasing the incidence of ROP, 
IVH, BPD, NEC and infections significantly.  
As a result, it is desirable that the newborn can increase the level of antioxidant 
protection to reestablish the oxido-reductive balance and to prevent the problems 
occurred from an extended exposure to high levels of free radicals and oxygen 
reactive species.  
Oxidative stress, as well as in the case of age diseases, is considered one of the 
main factors which determine the deterioration of the retina. The attempt to 
maintain a correct balance between oxidant and antioxidant factors can help to 
prevent or reduce damage to the eyes or other tissues that occur in the newborn, 
especially preterm.  
The premature birth is the most frequent cause of mortality, morbidity and 
disability. Premature babies have an extremly high risk to develop ocular or 
neurological lesions. The main complication at visual level that may appear is 
called retinopathy of prematurity, so called ROP. Oxidative stress is involved in 

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the etiology of this disease. In fact, premature babies, because of repiratory issues, 
are oftenly exposed to potentially damaging oxygen concentrations or to 
phototherapy with high blue light intensity. These therapuetical practices are 
sources of free radicals.  
The lutein and zeaxanthin present in the macular pigment, due to their capacity to 
absorb blue light and their antioxidant action, could have an important role in 
protecting the eyes of the newborn against damages produced by intense light.  
On adults, different elements suggest a protective action of lutein against photo-
oxidative damage, proved by numerous studies.  
The studies performed on babies showed that the levels of carotenoids in the first 
four / six months of life are much reduced. This is due to the fact that the baby’s 
diet is based exclusively on milk, without any solid elements (as vegetables or 
green leaves), sole sources of this nutrient. Nevertheless, breast fed babies, in 
average, present high plasmatic lutein levels than babies fed with prepared milk. 
Different milk formuli for newborns found at present time on the market are not 
enriched with this type of carotenoids, thus their content of lutein and zeaxanthin 
is very low, exceting certain formuli which are not traded in Italy prepared using 
egg mixes. Breast milk, is thus the only source of lutein for the newborn before 
ablactation, and breast feeding proves to be of considerable importance as 
primary source of these micronutrients for the newborn, proper development and 
visual function protection. Taking into consideration the correlation between the 
lutein in the blood and breast milk and the reduction of its levels, similar to all 
carotenoids, in milk, after 6 days from birth, there is already an important 
contribution of nutriments high in lutein during breast feeding. Such diet enriched 
in lutein is particularly important especially for the mothers of premature babies 
or babies having a small weight when born. In fact, premature babies and 
underwight babies need more nutritive substances essential to a fast grow, 
because they have not benefit from the contribution of highly nutritive and 
energetic substances transferred from their mothers during the last weeks of 
pregnancy. Also, the gastrointestinal and renal functions which are not completely 
developed reduce the absorption and withhold of important micronutrients, 
amongst which important antioxidants that protect the newborn from the exposure 
to high level of free radicals produced excessively at birth and several times as a 
result of the resuscitation techniques used. Breast feeding is important for the 
antioxidant contribution to the protection of the newborn and definitely the 
nutritional state of the mother has subsequently an essention part because it 
influences the nutrition of the newborn, especially concerning certain solvable 
nutritive elements, such as lutein and zeaxanthin.  
It should be emphasized that in the literature are already present searches and 
results with the use of lutein / zeaxanthin in the newborn.  
The recent Gong work has evaluated the role of lutein / zeaxanthin comparing the 
data obtained from various studies, including those of Romagnoli, Dani and 
Manzoni. Furthermore the RCT analysis of Rubin on the subject, it can be 
concluded that lutein / zeaxanthin are well tolerated and well absorbed from 
preterm infants also after oral administration. 
The extremely interesting result that has emerged although not statistically 
significant (probably due to the small sample) is that supplementation with lutein 
/ zeaxanthin reduced the incidence and severity of ROP. 
Our protocol is born from the idea that given the interesting results of earlier work 
is considered important to deepen a dosage of at least 1 ml / kg equal to 0,5 mg of 
lutein and 0.05 mg of zeaxanthin. 
It 'important to assess the value of the key markers of oxidative stress biological 

 5 
antioxidant potential (BPT) and total hydroperoxide (TH) during and after 
treatment.  
Already in a previous work (S. Perrone, M. Longini) has demonstrated a 
reduction in radicalemia in term infants, during and after administration of lutein / 
zeaxanthin by determination of the BTP and TH. 
Preparation based on lutein ans zeaxanthin have never reveled on humans 
negative or harmful effects after administration, or to the gastrointestinal or 
sistemis level. In recent studies there were not reported adverse phenomena after 
administrating 20 mg/day of lutein or zeaxanthin for a period of 6 months, or 
interactions with other liposovable nutritive elements.  
Justifying the non-
commercial 
character of the 
study  
This study is based on the administration of a dietary supplement of lutein/zeaxanthin.  
It is included in the category of a spontaneous/non-commercial pilot study, because it is 
born from the need of private healt care of identifying a natural antioxidant product 
which may reduce the severeness of the diseases related to the prenatal period, limiting 
the sufferance of newborns and their families, by reducing simultaneously the charges in 
SSN pregnancy which arise from the standard treatments and short-term and medium to 
long-term rehabilitation.  
It was chosen the product LUTEIN ofta 0,5 gocce, because Sooft Company proved to be 
able to supply this drug without any charges, also signing a statement that certifies the 
fact that the scientific results of the research will remain at the disposal of the scientific 
community and that the management of the intellectual property protection activity 
concerning any invention that may derive from the research is made accoding to the law 
in force and mainly to Art. 65 of the Executive Decree no. 30 from 10 February 2005 – 
„The Code of Industrial Property”.  In conclusion the results of the research will remain 
available for the Scientific Community and shall not be used for commercial purposes or 
profit.  
The 
registration 
and trading status 
of 
the 
product 
participating 
at 
the study  
The Registers of the Ministry of Health concerning non-pharmacological products  
The product is registeres in the Register of dietary supplements on the web 
site 
of 
the 
Ministry 
of 
Health 
(http://www.ministerosalute.it/alimenti/dietetica) and classified with the 
following code: 905619452, according to the executive decree no. 111 from 27 
January 1992. These products are submitted to the European Directive 
concerning food, according to the Executive Decree no. 169 from 21/05/2004, 
and to the European Directive 2001/20/EC concerning drugs, transposed to Italian 
level throyh the executive decree 211 from 24/06/2003. 
Ingredients: solution of 5% Lutein and 2,25% Zeaxanthin with excipients (Corn 
starch, glucose, potassium sorbate, xanthan gum, citric acid). 
Description: LUTEIN ofta 0,5 gocce is a dietary supplement based on lutein and 
zeaxanthin.  
The lutein and its isomer, zeaxanthin, are two carotenoids highly spreaded in 
nature, which cannot be synthetized by the human body. They are normaly 
absorbed through food rich in such carotenoids (vegetables with green leaves, 
with big leaves as turnips and spinach, and fruits such as apricots and kiwi) and 
through breast milk. After absorption, the lutein and zeaxanthin are distributed to 
all tissues, but they are selectively accumulating in the eyes. Mainly, they are 
focusing in the retina and macula lutea, the latter being the place where clear 
images are formed, whose development is complete around the 4th or 5th month of 
life. The lutein and zeaxanthin are the only pigments present at the level of 
macula lutea and have a protection role.  
They contribute and maintain the functionality and integrity of the eye’s sensitive 
structures (retina, iris, lens), preventing or reducing the damages caused by free 
radicals. In specialized literature is largely described their high antioxidant 

 6 
activity and the advantages of a consumption or supplement. Lutein and 
zeaxanthin pass through the placental barrier, they are also present in the 
colostrums and breast milk and it is believed that they take part to the 
embryogenesis of the retina and to the development of visual functions during the 
first weeks of life.  
As a result, the lutein and zeaxanthin are essential to the health of the eye, both on 
adults and children suring their first hours of life.  
Thus, the absorption of these substances proves to be necessary in situations of 
necessity growth or in case of deficient intake, both during the aging period of the 
ocular structures responsible for the visual function (macula), and during their 
conservation period.  
The lutein and zeaxanthin do not present contraindications and can be taken at 
any age.  
Use: 
LUTEIN ofta 0,5 gocce is indicated in situations of necessity growth or in case of 
deficient food intake of its components on different age groups.  
LUTEIN ofta 0,5 gocce can be useful especially in preventing macular or retina 
damages. 
Study Objectives 
Main objective  
To evaluate if the administration of pharmacology doses of Lutein/Zeaxanthin 
micronutrients in water (LUTEIN ofta 0,5 gocce – Neoox) is able to reduce the 
level of radicalemy and at the same time to elevate the antioxidant power of 
premature newborns (gestational age: ≤ of 32 weeks and / or weight at birth: ≤ 
1500 grams). 
Study scketch 
pilot study, non-commercial, with food supplement, treated vs. control with a 
ratio 1: 1 double-blind. The identical vials, corresponding to placebo and active 
product, have an alphanumeric code without meaning for the operator, but that 
identifies the traty from control, in an anonymous document kept by the 
Statistical. The document will be placed in a sealed and anonymous envelopeand 
it will be kept open by the statistician at the time of data analysis. 
People 
participating at 
the study and their 
number  
Inclusion criteria  
• Newborns with a weight ≤ 1.500 grams and/or gestational age ≤ 32 weeks; 
• Male and female newborns; 
• Newborns whose parents want to sign the information form – informed 
consent.  
 
Exclusion criteria  
• Informed consent is not signed 
• Infants of birth weight ≥ 1.500 gramms and/or gestational age > 32 weeks 
• infants hospitalized after 36 hours of life 
• Infants with ophthalmologic disease at randomization 
• infants with severe malformations 
 
Number of patients about to be registered  
It is expected to register a total number of 50 newborns divided in two groups:  
• Experimental group A: 25 newborns treated; 
• Control group B: 25 newborns treated. 
Randomization 
Subsequently enrollment patients will be randomly divided into Group A and 
Group B throught a web system that allows the randomization into three different 
recruitment centers 

 7 
Number of centres  Multicenter pilot study. 
At the study will participate three Italian experimental centres: Naples, Siena and 
Padova.  
The centre from Naples will be the national coordinator and the center from Siena 
will handle in a centralized way the laboratory results. The center from Padova 
will help to recruit an adequate number of cases. 
Sample size 
BAP and TH are two bio-markers with different hypothetical changes clearly 
different. For this reason we will use the study method proceeds by the following 
online site http://clincalc.com/stats/samplesize.aspx (Rosner B. Fundamentals of 
Biostatistics. 7th ed. Boston, MA: Brooks/Cole; 2011). 
The inserted reference values are for BAP 2361 (±466) mol/L and for TH 
156.75 (±64.0)  Ucarr  (Perrone S., Longini M. et. Al). 
The difference for BAP that we hypothesize to find is an increase of at least 500 
µmol / L which is approximately 20% of the control data. 
By setting α= 0.05% and β=0.1% with a power of 90% the number of samples 
required is 25 + 25 = 50. 
For the TH assume a decrease of 50 Ucarr which is approximately 30% of the 
data of the control. 
By setting α= 0.05% and β=0.2% with a power of '80% also in this case the 
required number of samples is 25 + 25 = 50. 
However 25 + 25 is the minimum number. Taking into account any ongoing study 
waivers (parents may request to discontinue treatment at any time) which go 
beyond statistical calculations. So in case of necessity we will recruit a number of 
infants to reach the minimum number according to the design of the protocol (25 
+ 25). 
Treatment and 
dosage 
Products administered: 
LUTEIN ofta 0,5 gocce, containing a solution of 5% Lutein and 2,25% 
Zeaxanthin with excipients (Corn starch, glucose, potassium sorbate, xanthan 
gum, citric acid) (group A) 
Placebo solution with unique excipients (Demineralised water, potassium sorbate, 
xanthan gum, citric acid) (group B) 
Experimental Group:  
Group A (25 newborns) will be treated with LUTEIN ofta 0,5 gocce, (1 ml per 
Kg equal to 0,5 mg of lutein and 0,05 of zeaxantin), divided in two additional 
administrations during the day from the standard hospital treatment foreseen. The 
first dose will be given within 36 hours of life, the least to 30th day of life. 
Control Group:  
Group B (25 newborns) treated with Placebo solution (additionaly to the standard 
hospital treatment foreseen. The first dose will be given within 36 hours of life, 
the least to 30th day of life. 
Way of intake 
The product will be administered by adding it in the milk (human or formulae), or 
in a small quantity of glucose, either orally or by gavage.  
Duration of the 
period of 
administration  
The administration of the product (LUTEIN ofta 0,5 gocce) starts within the first 
36 hours of life and continues with daily administration for 30 days. 
Study duration 
Duration of the observation period of the patient registered  
Since birth to hospital discharge.  
Total duration of the study: 
The study will have a duration of 1 year: the first 6 months will be used to register 
the newborns in the centers. During this period, there will also be performed the 

 8 
laboratory investigations foreseen. The second semester will be used to study and 
analyse the results achieved.  
Procedures 
 
Methodology: 
When born, premature newborns that are comply with the inclusion parameters 
will be introduced and separated in two random groups (A and B).  
All newborns, during the observation period, will be submitted to the blood 
collection (1 ml) from the umbilical cord and peripheral (at the same time with 
the routine collections) on which there will be performed blood gas analysis and 
oxidative stress markers (TH and BAP). All registered newborns will also be 
submitted to the verification of their history concerning the examination and 
collection, in view of evaluation the presence or absence of ROP, NEC, IVH, 
BPD and infections.   
Collection Time  
• T0, basic at birth, before begining the treatment: blood collection from the 
umbilical vein.  
• T1, first check, to 15 days after initiation of treatment: peripheral blood 
collection in view of verifying it before the Lutein/zeaxanthin 
administration. 
• T2, second check, at 30th day since the begining of treatment: peripheral 
blood collection in view of verifying it before the Lutein/zeaxanthin 
administration. 
 
The parents will be informed concerning the experimental procedure and the 
checks schedules.  
It will be required the written consent of the parents.  
The protocol shall be submitted to approval to the local ethics commission.  
  
Evaluation Parameters:  
Efficiency: 
a) Evaluation of oxidative stress biomarkers in the peripheral blood of the 
premature newborn before and after the treatment.  
 
Tolerability: 
There will be transcribed on the data sheet possible adverse events which may be 
observed by the doctor.  
 
Evaluation Scale  
a) Evaluation of the oxidative stress: by deremining the oxidative stress 
biomarkers and registering them in the data sheet.  
b) They must be indicated: 
Demographic Characteristics 
• Sex 
• Gestational Age 
• Weight (with percentile) 
• Mode of delivery 
• Preeclampsia 
• Premature rupture of membranes 
• Using steroids before birth 
• Using antibiotics before birth 
• Use of drugs or harmful substance before birth 
       Clinical features 

 9 
• Apgar score 
• Use of surfactant 
• Umbilical catheter 
• CVC location and duration 
• Intubation 
• Mechanical ventilation (procedures and time) 
• Supplementation of O2 
• Incidence of infections 
• Use and type of antibiotics 
• Use and type of antifungal 
• Use and type of post-natal steroids 
• Use and type inotropic 
• Use of NPT 
• Duration of treatment in NICU 
          Nutritional Characteristics: 
• Oral feeding start time 
• Exclusive oral feeding start time 
• Fluid volume 
• Intake calories (protein, carbohydrates and fats) 
• Use of maternal and /or uman milk 
 
Other therapies associated and/or permitted  
During the trial period it is not permitted any product administration or 
antioxidant activities (anti-radicals) or products which contain even a sole 
component having this result, excepting the protocol.  
Basic examination 
 
At birth, as it is foreseen by newborn protocols, the babies will be submitted to 
several medical examinations.  
Control 
examination 
From the Birthing Unit, the newborns will be tranfered to intensive care rooms 
where they will be submitted to multiple control examinations.  
Follow-up 
examinations 
As it is foreseen in neonatal protocols. 
Statistical Analysis The Student t test for independent data is the type of analysis that will be used to 
assess statistically significant differences between the parameters recorded in the 
two groups (treated and control). The Student t test is the method of choice for 
analysis as it allows to evaluate the values of a continuous random variable 
measured in not very many samples (25 subjects per group). It will be using the 
statistical package SPSS system. 
 
 
 
 
 
 
 
 
 
REFERENCES 
 

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Lutein: description, pharmacokinetics activity and characteristics, mechanism of action, 
safety and tolerability  
 
1. Shao, A. and Hathcock, JN. Risk assessment for the carotenoids lutein and lycopene. 
Regul Toxicol Pharmacol. 2006 Aug;45(3):289-98.  
2. Khachik F, London E, de Moura FF, Johnson M, Steidl S, Detolla L, Shipley S, Sanchez 
R, Chen XQ, Flaws J, Lutty G, McLeod S, Fowler B. Chronic Ingestion of (3R,3’R,6’R)-
Lutein and (3R,3’R)- Zeaxanthin in the Female Rhesus Macaque. Invest Ophthalmol Vis 
Sci. 2006 Dec;47(12):5476-86.  
3. Khachik F, de Moura FF, Chew EY, Douglass LW, Ferris FL 3rd, Kim J, Thompson DJ. 
The effect of lutein and zeaxanthin supplementation on metabolites of these carotenoids 
in the serum of persons aged 60 or older. Invest Ophthalmol Vis Sci. 2006 
Dec;47(12):5234-42.  
4. Trevithick-Sutton CC, Foote CS, Collins M, Trevithick JR. The retinal carotenoids 
zeaxanthin and lutein scavenge superoxide and hydroxyl radicals: a chemiluminescence 
and ESR study. Mol Vis. 2006 Sep 30;12:1127-35.  
5. Thürmann PA, Schalch W, Aebischer JC, Tenter U, Cohn W. Plasma kinetics of lutein, 
zeaxanthin, and 3-dehydro-lutein after multiple oral doses of a lutein supplement. Am J 
Clin Nutr. 2005 Jul;82(1):88-97.  
6. Rajendran V, Pu YS, Chen BH. An improved HPLC method for determination of 
carotenoids in human serum. J Chromatogr B Analyt Technol Biomed Life Sci. 2005 Sep 
25;824(1-2):99-106.  
7. During A, Dawson HD, Harrison EH. Carotenoid transport is decreased and expression of 
the lipid transporters SR-BI, NPC1L1, and ABCA1 is downregulated in Caco-2 cells 
treated with ezetimibe. J Nutr. 2005 Oct;135(10):2305-12 
8. Reboul E, Abou L, Mikail C, Ghiringhelli O, André M, Portugal H, Jourdheuil-Rahmani 
D, Amiot MJ, Lairon D, Borel P. Lutein transport by Caco-2 TC-7 cells occurs partly by 
a facilitated process involving the scavenger receptor class B type I (SR-BI). Biochem J. 
2005 Apr 15;387(Pt 2):455-61.  
9. Lutein and zeaxanthin. Monograph. Altern Med Rev. 2005 Jun;10(2):128-35 
10. Krinsky NI, Landrum JT, Bone RA. Biologic mechanisms of the protective role of lutein 
and zeaxanthin in the eye. Annu Rev Nutr. 2003;23:171-201. Epub 2003 Feb 27. Review.  
11. Tyssandier V, Reboul E, Dumas JF, Bouteloup-Demange C, Armand M, Marcand J, 
Sallas M, Borel P. Processing of vegetable-borne carotenoids in the human stomach and 
duodenum. Am J Physiol Gastrointest Liver Physiol. 2003 Jun;284(6):G913-23. Epub 
2003 Jan 10 
12. Cardinault N, Gorrand JM, Tyssandier V, Grolier P, Rock E, Borel P. Short-term 
supplementation with lutein affects biomarkers of lutein status similarly in young and 
elderly subjects. Exp Gerontol. 2003 May;38(5):573-82.  
13. Krinsky NI. Possible biologic mechanisms for a protective role of xanthophylls. J Nutr. 
2002 Mar;132(3):540S-542S. Review.  
14. Granado F, Olmedilla B, Blanco I. Nutritional and clinical relevance of lutein in human 
health. Br J Nutr. 2003 Sep;90(3):487-502. Review.  
 
 
 
 
 
 
 
Lutein in Neonatology  

 11 
15. Giuseppe Buonocore, Monica Tei, Serafina Perrone. Lutein as protective agent against  
neonatal oxidative stress. Journal of Pediatric and Neonatal Individualized Medicine  
2014;3(2):e030244. 
16. Perrone S, Tei M, Longini M, Santacroce A, Turrisi G, Proietti F, Felici C, Picardi A, 
Bazzini F, Vasarri P, Buonocore G. Lipid and protein oxidation in newborn infants after 
lutein administration. Oxid Med Cell Longev. 2014;2014:781454. doi: 
10.1155/2014/781454. Epub 2014 Apr 30. 
17. Perrone S, Longini M, Marzocchi B, Picardi A, Bellieni CV, Proietti F, Rodriguez A, 
Turrisi G, Buonocore G. Effects of lutein on oxidative stress in the term newborn: a pilot 
study. Neonatology. 2010;97(1):36-40. doi: 10.1159/000227291. Epub 2009 Jul 7.  
18. Shoji H, Koletzko B. Oxidative stress and antioxidant protection in the perinatal period. 
Curr Opin Clin Nutr Metab Care. 2007 May;10(3):324-8. Review.  
19. Fokkelman K, Haase E, Stevens J, Idikio H, Korbutt G, Bigam D, Cheung PY. Tissue-
specific changes in glutathione content of hypoxic newborn pigs reoxygenated with 21% 
or 100% oxygen. Eur J Pharmacol. 2007 May 7;562(1-2):132-7. Epub 2007 Feb 8.  
20. Franco MC, Akamine EH, Rebouças N, Carvalho MH, Tostes RC, Nigro D, Fortes ZB. 
Long-term effects of intrauterine malnutrition on vascular function in female offspring: 
implications of oxidative stress. Life Sci. 2007 Jan 30;80(8):709-15. Epub 2006 Nov 11.  
21. Mercer JS, Erickson-Owens DA, Graves B, Haley MM. Evidence-based practices for the 
fetal to newborn transition. J Midwifery Womens Health. 2007 May-Jun;52(3):262-72. 
Review. 
22. Kopsell DA, Lefsrud MG, Kopsell DE, Wenzel AJ, Gerweck C, Curran-Celentano J. 
Spinach cultigen variation for tissue carotenoid concentrations influences human serum 
carotenoid levels and macular pigment optical density following a 12-week dietary 
intervention. J Agric Food Chem. 2006 Oct 18;54(21):7998-8005 
23. Fanaris, Bel BO, Guidettic E et al. Ruolo della Luteina nella prevenzione delle patologie 
oculari nel neonato. Rivista Italiana di Medicina Pediatrica 2006;numero speciale:51-53.  
24. Kvansakul J, Rodriguez-Carmona M, Edgar DF, Barker FM, Köpcke W, Schalch W, 
Barbur JL. Supplementation with the carotenoids lutein or zeaxanthin improves human 
visual performance. Ophthalmic Physiol Opt. 2006 Jul;26(4):362-71.  
25. Rodriguez-Carmona M, Kvansakul J, Harlow JA, Köpcke W, Schalch W, Barbur JL. The 
effects of supplementation with lutein and/or zeaxanthin on human macular pigment 
density and colour vision. Ophthalmic Physiol Opt. 2006 Mar;26(2):137-47 
26. Provis JM, Penfold PL, Cornish EE, Sandercoe TM, Madigan MC. Anatomy and 
development of the macula: specialisation and the vulnerability to macular degeneration. 
Clin Exp Optom. 2005 Sep;88(5):269-81. Review. 
27. Yanoff M and Duker i.S (2005) “Ophthalmology” Edizione italiana ed 2003 ristampa 
2005, Antonio Delfino Editore medicina-scienze, volume 1, cap 1.3  
28. Santosa S, Jones PJ. Oxidative stress in ocular disease: does lutein play a protective role? 
CMAJ. 2005 Oct 11;173(8):861-2.  
29. van Leeuwen R, Boekhoorn S, Vingerling JR, Witteman JC, Klaver CC, Hofman A, de 
Jong PT. Dietary intake of antioxidants and risk of age-related macular degeneration. 
JAMA. 2005 Dec 28;294(24):3101-7.  
30. Schweigert FJ, Bathe K, Chen F, Büscher U, Dudenhausen JW. Effect of the stage of 
lactation in humans on carotenoid levels in milk, blood plasma and plasma lipoprotein 
fractions. Eur J Nutr. 2004 Feb;43(1):39-44. Epub 2004 Jan 6 
31. Jewell VC, Mayes CB, Tubman TR, Northrop-Clewes CA, Thurnham DI. A comparison 
of lutein and zeaxanthin concentrations in formula and human milk samples from 
Northern Ireland mothers. Eur J Clin Nutr. 2004 Jan;58(1):90-7.  
32. Nolan J, O'Donovan O, Kavanagh H, Stack J, Harrison M, Muldoon A, Mellerio J, Beatty 
S. Macular pigment and percentage of body fat. Invest Ophthalmol Vis Sci. 2004 
Nov;45(11):3940-50.  

 12 
33. Turgut M, Basaran O, Cekmen M, Karatas E, Kurt A, Aygun AD. Oxidant and 
antioxidant Ievels in preterm newborns with idiopathic hyperbilirubinaemia. J Paediatr 
Child Health. 2004 Nov;40(11):633-7.  
34. Richer S, Stiles W, Statkute L, Pulido J, Frankowski J, Rudy D, Pei K, Tsipursky M, 
Nyland J. Double-masked, placebo-controlled, randomized trial of lutein and antioxidant 
supplementation in the intervention of atrophic age-related macular degeneration: the 
Veterans LAST study (Lutein Antioxidant Supplementation Trial). Optometry. 2004 
Apr;75(4):216-30.  
35. Vento M, Asensi M, Sastrei, LioretA, Garcia-Sala F, Vina (2003) i. Oxidative stress in 
asphyxiated term infants resuscitated with 100% oxygen. J Pediatr 2003;142:240-6.  
36. Broekmans WM, Berendschot TT, Klöpping-Ketelaars IA, de Vries AJ, Goldbohm RA, 
Tijburg LB, Kardinaal AF, van Poppel G. Macular pigment density in relation to serum 
and adipose tissue concentrations of lutein and serum concentrations of zeaxanthin. Am J 
Clin Nutr. 2002 Sep;76(3):595-603.  
37. Gossage CP et al (2002) “ Carotenoid composition of milk during the first month 
postpartum and the response to b-carotene supplementation” Am J Clin Nutr 76; 193-7.  
38. Jewell VC, Northrop-Clewes CA, Tubman R, Thurnham DI. Nutritional factors and 
visual function in premature infants. Proc Nutr Soc. 2001 May;60(2):171-8. Review.  
39. Vento M, Asensi M, Sastre J, García-Sala F, Pallardó FV, Viña J. Resuscitation with 
room air instead of 100% oxygen prevents oxidative stress in moderately asphyxiated 
term neonates. Pediatrics. 2001 Apr;107(4):642-7.  
40. Age-Related Eye Disease Study Research Group. A randomized, placebo-controlled, 
clinical trial of high-dose supplementation with vitamins C and E, beta carotene, and zinc 
for age-related macular degeneration and vision loss: AREDS report no. 8. Arch 
Ophthalmol. 2001 Oct;119(10):1417-36. Erratum in: Arch Ophthalmol. 2008 
Sep;126(9):1251.  
41. Sommerburg O, Meissner K, Nelle M, Lenhartz H, Leichsenring M. Carotenoid supply in 
breast-fed and formula-fed neonates. Eur J Pediatr. 2000 Jan-Feb;159(1-2):86-90.  
42. Grantham-McGregor SM, Walker SP, Chang S. Nutritional deficiencies and later 
behavioural development. Proc Nutr Soc. 2000 Feb;59(1):47-54. Review 
43. Kiely M, Cogan PF, Kearney PJ, Morrissey PA. Concentrations of tocopherols and 
carotenoids in maternal and cord blood plasma. Eur J Clin Nutr. 1999 Sep;53(9):711-5.  
44. Yeum K.J et al (1998) “Relationship of plasma carotenoids, retinol and tocopherols in 
Mothers and Newborn infants”. J of American College of Nutrition 17(5): 442-7.  
45. Oostenbrug G.S. et al (1998) “Maternal and neonatal plasma antiossidant levels in normal 
pregnancy, and the relationship with fatty acid unsaturation”. Br. J of Nutrition 80: 67-73.  
46. Bonn D. Keeping the stork at bay until the time is right. Lancet. 1998 Feb 
21;351(9102):576 
47. Sommerburg O, Keunen JE, Bird AC, van Kuijk FJ. Fruits and vegetables that are 
sources for lutein and zeaxanthin: the macular pigment in human eyes. Br J Ophthalmol. 
1998 Aug;82(8):907-10 
48. Jackson JG, Eric L, Lien A, Sharon J, White B, Nicholas J, Bruns C, Charles F, Kuhlman 
A. Major carotenoids in mature human milk: longitudinal and diurnal patterns. The 
Journal of Nutritional Biochemistry 1998 Jan;9(1):2-7.  
49. Khachik F, Spangler CJ, Smith JC Jr, Canfield LM, Steck A, Pfander H. Identification, 
quantification, and relative concentrations of carotenoids and their metabolites in human 
milk and serum. Anal Chem. 1997 May 15;69(10):1873-81 
50. Landrum JT, Bone RA, Joa H, Kilburn MD, Moore LL, Sprague KE. A one year study of 
the macular pigment: the effect of 140 days of a lutein supplement. Exp Eye Res. 1997 
Jul;65(1):57-62.  

 13 
51. Leung AK, Siu TO, Chiu AS, Robson WL, Larsen TE. Serum carotene concentrations in 
normal infants and children. Clin Pediatr (Phila). 1990 Oct;29(10):575-8; discussion 579-
80.  
52. Nakamura H, Lee Y, Uetani Y, Kitsunezuka Y, Shimabuku R, Matsuo T. Effects of 
phototherapy on serum unbound bilirubin i icteric newborn infants. Biol Neonate. 
1981;39(5-6):295-9.  

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