Elisabeth De Greef

Probiotics and prebiotics in prevention and treatment of diseases in infants and children

OBJECTIVE To evaluate the impact of probiotics and prebiotics on the health of children. SOURCES MEDLINE and LILACS were searched for relevant English and French-language articles. SUMMARY OF THE FINDINGS Human milk is rich in prebiotic oligosaccharides and may contain some probiotics. No data suggest that addition of probiotics to infant formula may be harmful, but evidence of its efficacy is insufficient for its recommendation. Since data suggest that addition of specific prebiotic oligosaccharides may reduce infections and atopy in healthy infants, their addition to infant formula seems reasonable. Long-term health benefits of pro- and prebiotics on the developing immune system remain to be proven. Selected probiotics reduce the duration of infectious diarrhea by 1 day, but evidence in prevention is lacking, except in antibiotic-associated diarrhea. Some specific probiotics prevent necrotizing enterocolitis, and other microorganisms may be beneficial in Helicobacter pylori gastritis and in infantile colic. Evidence is insufficient to recommend probiotics in prevention and treatment of atopic dermatitis. The use of probiotics in constipation, irritable bowel syndrome, inflammatory bowel disease, and extra-intestinal infections requires more studies. CONCLUSIONS Duration of administration, microbial dosage, and species used need further validation for both pro- and prebiotics. Unjustified health claims are a major threat for the pro- and prebiotic concept.

Diagnosis and management of cow's milk protein allergy in infants

BackgroundCow’s milk protein allergy (CMPA) is frequently suspected in infants with a variety of symptoms. A thorough history and careful clinical examination are necessary to exclude other underlying diseases and to evaluate the severity of the suspected allergy. Care should be taken to diagnose CMPA adequately to avoid an unnecessary diet.Data sourcesWe make recommendations based on systematic literature searches using the best-available evidence from PubMed, Cumulative Index to Nursing and Allied Health Literature, and bibliographies.ResultsSkin prick tests, patch tests and serum specific IgE are only indicative of CMPA. Breastfed infants have a decreased risk of developing CMPA; an elimination diet for the mother is indicated if CMPA is confirmed. If a food challenge is positive in formula fed infants, an extensively hydrolysed formula and cow’s milk-free diet is recommended. If symptoms do not improve, an amino acid based formula should be considered. In severe CMPA with life-threatening symptoms, an amino-acid formula is recommended.ConclusionsElimination diet by a double-blind placebo controlled food challenge is the gold standard for diagnosis. Elimination of the offending allergen from the infants’ diet is the main treatment principle.

Gastrointestinal manifestations of cow's milk protein allergy and gastrointestinal motility.

Cow’s milk protein allergy (CMPA) may cause gastrointestinal motility disorders. Symptoms of both conditions overlap and diagnostic tests do not reliably differentiate between both. A decrease of symptoms with an extensive hydrolysate and relapse during challenge is not a proof of allergy, because hydrolysates enhance gastric emptying, a pathophysiologic mechanism of gastro‐oesophageal reflux (GER). Thickened formula reduces regurgitation, and failure to do so suggests CMPA. A thickened extensive hydrolysate may induce more rapid improvement, but does not always differentiate between CMPA and GER. Different hypotheses are discussed: is the overlap between CMPA and functional disorders coincidence, or do both entities present with identical symptoms, or does the fact that symptoms are identical indicates that there is only one entity involved? Studies on the prevention of CMPA focused on ‘at‐risk families’, and resulted in a decrease of CMPA and atopic dermatitis, but did not provide data on the incidence of GER.

Soy infant formula: is it that bad?

The objective of this study is to review the indications of soy infant formula (SIF). Structured review of publications is made available through standard search engines (Pubmed,…). The medical indications for SIF are limited to galactosaemia and hereditary lactase deficiency. In the treatment of cow’s milk allergy, SIF is used for economic reasons, as extensive hydrolysates are expensive. SIF is dissuaded mainly because of its phytooestrogen content. Isoflavone serum levels are much higher in SIF‐fed infants than in breastfed or cow milk formula–fed infants. Administration of pure isoflavones to animals causes decreased fertility, but clinically relevant adverse effects of SIF in infants are not reported.

Prebiotics in infant formula

The gastrointestinal microbiota of breast-fed babies differ from classic standard formula fed infants. While mothers milk is rich in prebiotic oligosaccharides and contains small amounts of probiotics, standard infant formula doesn’t. Different prebiotic oligosaccharides are added to infant formula: galacto-oligosaccharides, fructo-oligosaccharide, polydextrose, and mixtures of these. There is evidence that addition of prebiotics in infant formula alters the gastrointestinal (GI) microbiota resembling that of breastfed infants. They are added to infant formula because of their presence in breast milk. Infants on these supplemented formula have a lower stool pH, a better stool consistency and frequency and a higher concentration of bifidobacteria in their intestine compared to infants on a non-supplemented standard formula. Since most studies suggest a trend for beneficial clinical effects, and since these ingredients are very safe, prebiotics bring infant formula one step closer to breastmilk, the golden standard. However, despite the fact that adverse events are rare, the evidence on prebiotics of a significant health benefit throughout the alteration of the gut microbiota is limited.

An extensively hydrolysed rice protein-based formula in the management of infants with cow's milk protein allergy: preliminary results after 1 month

Background Guidelines recommend extensively hydrolysed cows milk protein formulas (eHF) in the treatment of infants diagnosed with cows milk protein allergy (CMPA). Extensively hydrolysed rice protein infant formulas (eRHFs) have recently become available, and could offer a valid alternative. Methods A prospective trial was performed to evaluate the clinical tolerance of a new eRHF in infants with a confirmed CMPA. Patients were followed for 1 month. Clinical tolerance of the eRHF was evaluated with a symptom-based score (SBS) and growth (weight and length) was monitored. Results Thirty-nine infants (mean age 3.4 months, range 0.5–6 months) diagnosed with CMPA were enrolled. All infants tolerated the eRHF and experienced a normal growth. Conclusions In accordance with current guidelines, this eRHF is tolerated by more than 90% of children with proven CMPA with a 95% CI, and is an adequate alternative to cows milk-based eHF. Trial registration number ClinicalTrials.gov NCT01998074.

Infliximab as Salvage Therapy in Paediatric Intestinal Transplant With Steroid- and Thymoglobulin-resistant Late Acute Rejection

Received August 12, 201 From the Division of Hospital for Sick Chi enterology, Hepatolog zTransplant centre, t Children, Toronto, Ca and Liver Disease, t Children’s Medical #Department of Pedi Santiago, Chile. Address correspondence Division of Gastroent Sick Children, 555 U (e-mail: yaron.avitzur The authors report no co Copyright # 2012 by E Hepatology, and Nut Gastroenterology, He DOI: 10.1097/MPG.0b01

Opportunistic infections in paediatric inflammatory bowel disease patients

Inflammatory bowel disease (IBD) is a chronic relapsing and remitting disease that is increasing in incidence throughout the Western world.1 Although multiple questions regarding its aetiology remain, immunosuppressive therapy is used as the mainstream treatment in both adults and children.2 Concerns have been raised regarding theirsafety and potential side effects on a short-term and long-term basis. Several databases have been initiated to evaluate this effect. Based on recent reports of an increased incidence of hepatosplenic T cell lymphoma in young male IBD patients receiving a combination therapy of anti-tumour necrosis factor antibodies and azathioprine (Aza), malignancy is the most dreaded complication.3 Nevertheless, as in all immunosuppressed patients, opportunistic infections are an important caveat.4 Here, we would like to focus on the risk for opportunistic infections due to immunosuppression in paediatric IBD and various aspects of prevention. Unfortunately, because paediatric data on this topic are scarce, data from adult IBD and rheumatoid arthritis populations are included. Any patient receiving a daily dose of 20 mg prednisone or more for 14 days should be considered immunosuppressed.5 Although current management often prescribes corticosteroids as an induction therapy, recurrent use is being limited due to multiple side effects and a loss of efficacy.6 To maintain remission, early introduction of Aza or 6-mercaptopurine has become the standard of care in most centres.7 It is generally prescribed after confirmation of normal thiopurine methyl transferase levels and genotype,8 as they reflect the risk of severe side effects of these medications. Over the last 10 years, biologicals, monoclonal antibodies blocking specific cytokines or cytokine–receptor interactions, were introduced with great success in adults and children for IBD treatment. For the induction and maintenance of mild to moderate Crohns disease, its efficacy appeared to be better in children than in adults.9 …

Safety of a thickened extensive casein hydrolysate formula

OBJECTIVES Cows milk allergy (CMA) is treated in formula-fed infants with an extensive protein hydrolysate. This study aimed to evaluate the nutritional safety of a non-thickened and thickened extensively casein hydrolyzed protein formula (NT- and T-eCHF) in infants with CMA. METHODS Infants younger than 6 mo old with a positive cow milk challenge test, positive IgE, or skin prick test for cow milk were selected. Weight and length were followed during the 6 mo intervention with the NT-eCHF and T-eCHF. RESULTS A challenge was performed in 50/71 infants with suspected CMA and was positive in 34/50. All children with confirmed CMA tolerated the eCHF. The T-eCHF leads to a significant improvement of the stool consistency in the whole population and in the subpopulation of infants with proven CMA. Height and weight evolution was satisfactory throughout the 6 mo study. CONCLUSIONS The eCHF fulfills the criteria of a hypoallergenic formula and the NT- and T-eCHF reduced CMA symptoms. Growth was within normal range.

Probiotics and prebiotics in pediatric diarrheal disorders

Introduction: In pediatrics, prebiotics and/or probiotics are added to infant formula, mainly to prevent diseases such as diarrheal disorders. Probiotic food supplements and medication are frequently used in the treatment of diarrheal disorders. This paper reviews the recent published evidence on these topics. Areas covered: Relevant literature published using PubMed and CINAHL was collected and reviewed. Recent review papers were give special attention. Expert opinion: The addition of pre- and/or probiotics to infant formula seems not harmful, but the evidence for benefit is limited. Most probiotics are commercialized as food supplements, and therefore do not qualify for medication legislation. Worldwide, Saccharomyces boulardii is the only strain which is registered as “medication” in the majority of countries. Efficacy data can only be considered if performed with the commercialized product. Some products reduce the risk for antibiotic-associated diarrhea and reduced the duration of acute infectious diarrhea with about 24 h. Overall, data in the other indications (inflammatory bowel disease, irritable bowel syndrome) are disappointing, although there are some recent promising results. The use of food supplements as medication opens the discussion to create a category of “medical food.”