Agus Firmansyah

Natural evolution of regurgitation in healthy infants

Objectives:  To determine the natural history of infant regurgitation during the first year of life.

Randomized Trial of Probiotics and Calcium on Diarrhea and Respiratory Tract Infections in Indonesian Children

OBJECTIVE: To investigate the effects of calcium and probiotics on the incidence and duration of acute diarrhea and acute respiratory tract infections (ARTIs) in low-socioeconomic communities of Jakarta, Indonesia. METHODS: We conducted a 6-month, double-blind, placebo-controlled study in 494 healthy children aged 1 to 6 years who received low-lactose milk with low calcium content (LC; ∼50 mg/day; n = 124), regular calcium content (RC; ∼440 mg/day; n = 126), RC with 5.108 colony-forming units per day of Lactobacillus casei CRL431 (casei; n = 120), or RC with 5.108 colony-forming units per day of Lactobacillus reuteri DSM17938 (reuteri; n = 124). Number and duration of diarrhea and ARTIs episodes were primary and secondary outcomes, respectively. RESULTS: Incidence of World Health Organization–defined diarrhea (≥3 loose/liquid stools in 24 hours) was not significantly different between RC and LC (relative risk [RR]: 0.99 [95% confidence interval (CI): 0.62–1.58]), between casei and RC (RR: 1.21 [95% CI: 0.76–1.92]), or between reuteri and RC (RR: 0.76 [95% CI: 0.46–1.25]) groups. Incidence of all reported diarrhea (≥2 loose/liquid stools in 24 hours) was significantly lower in the reuteri versus RC group (RR: 0.68 [95% CI: 0.46–0.99]). Irrespective of the definition used, reuteri significantly reduced diarrhea incidence in children with lower nutritional status (below-median height-and-weight-for-age z score). None of the interventions affected ARTIs. CONCLUSIONS: RC milk, alone or with L casei, did not reduce diarrhea or ARTIs in Indonesian children. L reuteri may prevent diarrhea, especially in children with lower nutritional status.

Burden of Severe Rotavirus Diarrhea in Indonesia

Globally, rotavirus is the leading cause of diarrhea-related hospitalizations and deaths among young children, but the burden of rotavirus disease in Indonesia is poorly documented. From January through December 2006, we conducted prospective surveillance (inpatient and outpatient) among children aged <5 years at 6 hospitals in 6 provinces of Indonesia, using standardized methodology. Of 2240 enrolled children hospitalized for diarrhea, 1345 (60%) were rotavirus positive. Of 176 children enrolled in outpatient clinics in 3 hospitals, 73 (41%) were rotavirus positive. Among children hospitalized for diarrhea, dehydration was more common among those who tested positive for rotavirus than among those who did not (91% vs 82%; P < .05), as was vomiting (86% vs 67%; P < .05). Children aged 6-23 months experienced 72% of all rotavirus episodes. Rotavirus prevalence increased slightly in the cool, dry season. The most commonly detected genotypes were G9 (30%) and P[6] (56%). G1P[6] and G9P[6] accounted for 34% and 21% of strains, respectively. A high proportion of genotype P[6] was detected, in combination with the common G types G1 and G9. Available rotavirus vaccines would likely be efficacious against the most common circulating strains, but continued monitoring of uncommon genotypes is needed.

Natural Evolution of Infantile Regurgitation Versus the Efficacy of Thickened Formula

Background: Regurgitation is frequent in infants. We evaluated changes in regurgitation among patient groups fed standard formula, standard formula subsequently thickened with cereal, or formula manufactured with bean gum as a thickening agent. Patients and Methods: A prospective, blinded, randomised 1-month intervention trial evaluating the efficacy of parental reassurance of the regurgitating child in combination with 3 formula interventions—standard infant formula (group A); 5 g of rice cereal added to 100 mL standard formula (group B); and formula manufactured with bean gum as a thickening agent (group C)—was performed in 60 infants presenting with more than 4 episodes of regurgitation and/or vomiting per day during the week before inclusion. Formula intake, infant comfort, stool aspects, and weight gain were evaluated. All of the infants and data recorded by parents in a diary were evaluated weekly by a blinded health care professional. Results: At baseline, groups A, B, and C were similar for all of the parameters. After the 1-month intervention, regurgitation/vomiting decreased significantly in all 3 groups (P < 0.0005). Although the decrease was largest in group C (−4.2 ± 2.1 episodes/day), the incidence did not differ significantly with groups A or B. At no evaluation interval was there a difference in volume of formula intake, infant comfort, stool frequency, or aspect. After 1 month, weight gain was significantly greater in group C compared with group A (19.9% vs 16.4%; P < 0.001). Conclusions: Thickening of formula decreases regurgitation, but not significantly. Parental reassurance remains the cornerstone of the treatment of infant regurgitation.

Probiotics Lactobacillus reuteri DSM 17938 and Lactobacillus casei CRL 431 Modestly Increase Growth, but Not Iron and Zinc Status, among Indonesian Children Aged 1–6 Years

Probiotics and milk calcium may increase resistance to intestinal infection, but their effect on growth and iron and zinc status of Indonesian children is uncertain. We investigated the hypotheses that cow milk with added probiotics would improve growth and iron and zinc status of Indonesian children, whereas milk calcium alone would improve growth but reduce iron and zinc status. A 6-mo randomized trial was conducted in low-socioeconomic urban communities of Jakarta. Healthy children (n = 494) were randomly assigned to receive low-lactose milk with a low calcium content of ∼50 mg/d (LC; n = 124), a regular calcium content of ∼440 mg/d (RC group; n = 126), regular calcium with 5 × 10(8) CFU/d Lactobacillus casei CRL 431 (casei; n = 120), or regular calcium with 5 × 10(8) CFU/d Lactobacillus reuteri DSM 17938 (reuteri; n = 124). Growth, anemia, and iron and zinc status were assessed before and after the intervention. Compared with the RC group, the reuteri group had significantly greater weight gain [0.22 (95% CI: 0.02, 0.42) kg], weight-for-age Z-score (WAZ) changes [0.09 (95% CI: 0.01, 0.17)], and monthly weight [0.03 (95% CI: 0.002, 0.05) kg/mo] and height [0.03 (95% CI: 0.01, 0.05) cm/mo] velocities. Casei significantly increased monthly weight velocity [0.03 (95% CI: 0.001, 0.05) kg/mo], but not height. However, the changes in underweight, stunting, anemia prevalence, and iron and zinc status were similar between groups. In conclusion, L. reuteri DSM 17938 modestly improved growth by increasing weight gain, WAZ changes, and weight and height velocity, whereas L. casei CRL 431 modestly improved weight velocity. Independent from probiotics supplementation, regular milk calcium did not affect growth or iron and zinc status.

Domperidone versus cisapride in the treatment of infant regurgitation and increased acid gastro‐oesophageal reflux: a pilot study

Aim: Although domperidone is used frequently to treat infant regurgitation, efficacy data are scarce. Cisapride was previously used in the same indication.

Malnutrition and diarrhea: Working Group Report of the First World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition.

Malnutrition is the lay term for protein-energy malnutrition (PEM), which results when the body’s needs for protein, energy fuels, or both cannot be satisfied by the diet. The entity includes a spectrum of clinical manifestations, depending on the relative intensity of protein or energy deficiency, the severity, and the duration of the deficiencies, the age of the individual, the cause of the deficiency, and the association with other nutritional or infectious diseases. Dietary protein and energy deficiencies usually occur together, but sometimes one predominates and if severe enough may lead to the clinical syndrome of kwashiorkor (predominantly protein deficiency) or marasmus (mainly energy deficiency). Marasmic-kwashiorkor is a combination of energy and protein deficiency. It may be difficult to recognize which of the deficiencies predominates in milder forms of the disease. The origin of PEM can be primary, when it is the result of inadequate food intake, or secondary, when it is the result of diseases that lead to low food ingestion, inadequate nutrient absorption, increased nutritional requirements, or increased nutrient losses (1). Protein-energy malnutrition is commonly assessed by weight for age, height for age, or weight for height. Waterlow (2) has suggested the terms “wasting” for a deficit in weight for height, and “stunting” for a deficit in height for age. Infants and children may then fall into one of four categories: a) normal; b) wasted but not stunted (suffering from acute PEM); c) wasted and stunted (suffering from acute and chronic PEM); and d) stunted but not wasted (past PEM with present adequate nutrition, or “nutritional dwarfs”). The intensity of the wasting and stunting can be graded by calculating weight as a percentage of the reference median weight for height, and height as a percentage of the reference median height for age. Other anthropometric measurements such as body mass index, arm circumference, and arm circumference to head circumference ratio have been used in children and adults to assess PEM. Many changes in biochemical or physiologic parameters have been noted in malnutrition, and some blood and serum tests have been used to evaluate PEM. However, these tests are not always available, not always easy to use, and are more expensive than anthropometric measurements. Diarrhea resulting from the malabsorption of water and nutrients is manifest by an increase in stool frequency, a decrease in stool consistency, or both. It is commonly associated with PEM. Persistent diarrhea is diarrhea that occurs every day for at least 14 days. It encompasses episodes of presumed infectious diarrhea that have an acute onset and persist for 2 weeks or longer but does not include known causes of chronic or recurrent diarrhea. Dysentery is diarrhea with visible blood present in the stool. In PEM, there is decreased gastric and pancreatic function. Bile production is normal to low, with a tendency for low conjugated bile acid concentrations. These changes in intestinal function coupled with a tendency for irregularities in intestinal motility and bacterial overgrowth increase the likelihood of diarrhea occurring in the malnourished infant or child. Infections of the gastrointestinal tract caused by viruses, bacteria, or parasites also may contribute to diarrhea. A cluster of risk factors has been identified by the World Health Organization that predispose infants and children to the development of persistent diarrhea. Included are: (a) host factors, such as young age, malnutrition, and impaired immune function; (b) environmental factors, among them overcrowding, inadequate hygiene, living in close contact with animals, and fecal–oral transmission of enteric pathogens; (c) previous infections, such as The input of Mabel Z. de Jimenez and Dilip Mahalanabil to this report is gratefully acknowledged. Journal of Pediatric Gastroenterology and Nutrition 35:S173–S179

Gluten and casein supplementation does not increase symptoms in children with autism spectrum disorder

A gluten‐ and casein‐free diet is often given to children with autism spectrum disorder (ASD). We aimed to determine the effect of gluten and casein supplementation on maladaptive behaviour, gastrointestinal symptom severity and intestinal fatty acids binding protein (I‐FABP) excretion in children with ASD.

Maladaptive Behavior and Gastrointestinal Disorders in Children with Autism Spectrum Disorder

Purpose Various gastrointestinal factors may contribute to maladaptive behavior in children with autism spectrum disorders (ASD). To determine the association between maladaptive behavior in children with ASD and gastrointestinal symptoms such as severity, intestinal microbiota, inflammation, enterocyte damage, permeability and absorption of opioid peptides. Methods This observational cross-sectional study compared children with ASD to healthy controls, aged 2-10 years. Maladaptive behavior was classified using the Approach Withdrawal Problems Composite subtest of the Pervasive Developmental Disorder Behavior Inventory. Dependent variables were gastrointestinal symptom severity index, fecal calprotectin, urinary D-lactate, urinary lactulose/mannitol excretion, urinary intestinal fatty acids binding protein (I-FABP) and urinary opioid peptide excretion. Results We did not find a significant difference between children with ASD with severe or mild maladaptive behavior and control subjects for gastrointestinal symptoms, fecal calprotectin, urinary D-lactate, and lactulose/mannitol ratio. Urinary opioid peptide excretion was absent in all children. Children with ASD with severe maladaptive behavior showed significantly higher urinary I-FABP levels compared to those with mild maladaptive behavior (p=0.019) and controls (p=0.015). Conclusion In our series, maladaptive behavior in ASD children was not associated with gastrointestinal symptoms, intestinal inflammation (no difference in calprotectin), microbiota (no difference in urinary D-lactate) and intestinal permeability (no difference in lactulose/manitol ratio). ASD children with severe maladaptive behavior have significantly more enterocyte damage (increased urinary I-FABP) than ASD children with mild maladaptive behavior and normal children.

Fructans in the first 1000 days of life and beyond, and for pregnancy.

Inulin-based prebiotics are non-digestible polysaccharides that influence the composition of the gut microbiota in infants and children, notably eliciting a bifidogenic effect with high short chain fatty acid levels. Inulin, a generic term that comprises β-(2,1)-linked linear fructans, is typically isolated from the chicory plant root, and derivatives such as oligofructose and long chain inulin appear to have different physiological properties. The first 1000 days of a childs life are increasingly recognized as a critical timeframe for health also into adulthood, whereby nutrition plays a key role. There is an ever increasing association between nutrition and gut microbiota composition and development, with life health status of an individual. This review summarizes the latest knowledge in the infant gut microbiota from preterms to healthy newborns, as well as in malnourished children in developing countries. The impact of inulin or mixtures thereof on infants, toddlers and young children with respect to intestinal function and immunity in general, is reviewed. Possible benefits of prebiotics to support the gut microbiome of malnourished infants and children, especially those with infections in the developing world, are considered, as well as for the pregnant mothers health. Importantly, novel insights in metabolic programming are covered, which are being increasing recognized for remarkable impact on long term offspring health, and eventual potential beneficial role of prebiotic inulins. Overall increasing findings prompt the potential for gut microbiota-based therapy to support health or prevent the development of certain diseases from conception to adulthood where inulin prebiotics may play a role.