Irene Axelsson

Probiotic bacteria in dietetic products for infants: A commentary by the ESPGHAN Committee on Nutrition

*University of Milano, Milano, Italy; †University of Lund, Malmo, Sweden; ‡University Children’s Hospital, Zurich, Switzerland (Committee guest); §Hopital Necker Enfants-Malades, Paris, France; Ludwig-Maximilians-University, Munich, Germany (Committee Chair); ¶The Royal Veterinary and Agricultural University, Frederiksberg, Denmark; #University of Liege, Liege, Belgium; **Meyer Children’s Hospital of Haifa, Israel; ††The Medical University of Warsaw, Warsaw, Poland (Committee Secretary); ‡‡University of Lille, Lille, France; §§University of Glasgow, Glasgow, United Kingdom.

Feeding preterm infants after hospital discharge : a commentary by the ESPGHAN Committee on Nutrition

ABSTRACT Survival of small premature infants has markedly improved during the last few decades. These infants are discharged from hospital care with body weight below the usual birth weight of healthy term infants. Early nutrition support of preterm infants influences long-term health outcomes. Therefore, the ESPGHAN Committee on Nutrition has reviewed available evidence on feeding preterm infants after hospital discharge. Close monitoring of growth during hospital stay and after discharge is recommended to enable the provision of adequate nutrition support. Measurements of length and head circumference, in addition to weight, must be used to identify those preterm infants with poor growth that may need additional nutrition support. Infants with an appropriate weight for postconceptional age at discharge should be breast-fed when possible. When formula-fed, such infants should be fed regular infant formula with provision of long-chain polyunsaturated fatty acids. Infants discharged with a subnormal weight for postconceptional age are at increased risk of long-term growth failure, and the human milk they consume should be supplemented, for example, with a human milk fortifier to provide an adequate nutrient supply. If formula-fed, such infants should receive special postdischarge formula with high contents of protein, minerals and trace elements as well as an long-chain polyunsaturated fatty acid supply, at least until a postconceptional age of 40 weeks, but possibly until about 52 weeks postconceptional age. Continued growth monitoring is required to adapt feeding choices to the needs of individual infants and to avoid underfeeding or overfeeding.

Iron metabolism and requirements in early childhood: Do we know enough?: A commentary by the ESPGHAN Committee on Nutrition

*University of Lancashire, Lancashire, United Kingdom; †University of Milano, Milano, Italy; ‡University of Lund, Malmo, Sweden; §Hopital des Enfants Malades, Paris, France; Hopital Necker Enfants-Malades, Paris, France, ¶Umea University, Umea, Sweden; #University of Munich, Munich, Germany; **Free University of Amsterdam, Amsterdam, The Netherlands; ††Royal Veterinary and Agricultural University, Frederiksberg, Denmark; ‡‡CHUV University Hospital, Lausanne, Switzerland; §§University of Liege, Liege, Belgium; Medical University of Warsaw, Warsaw, Poland; and ¶¶University of Glasgow, Glasgow, United Kingdom

Prebiotic oligosaccharides in dietetic products for infants: A commentary by the ESPGHAN committee on nutrition

This article by the ESPGHAN Committee on Nutrition summarizes available information on the effects of adding prebiotic oligosaccharides to infant and follow-on formulae. Currently there are only limited studies evaluating prebiotic substances in dietetic products for infants. Although administration of prebiotic oligosaccharides has the potential to increase the total number of bifidobacteria in feces and may also soften stools, there is no published evidence of clinical benefits of adding prebiotic oligosaccharides to dietetic products for infants. Data on oligosaccharide mixtures in infant formulae do not demonstrate adverse effects, but further evaluation is recommended. Combinations and dosages in addition to those so far studied need to be fully evaluated with respect to both safety and efficacy before their use in commercial infant food products. Well-designed and carefully conducted randomized controlled trials with relevant inclusion/exclusion criteria, adequate sample sizes and validated clinical outcome measures are needed both in preterm and term infants. Future trials should define optimal quantity and types of oligosaccharides with prebiotic function, optimal dosages and duration of intake, short and long term benefits and safety. At the present time, therefore, the Committee takes the view that no general recommendation on the use of oligosaccharide supplementation in infancy as a prophylactic or therapeutic measure can be made.

Bovine β-Lactoglobulin in the Human Milk

ABSTRACT. Human milk samples (n=232) collected during the whole lactation period from 25 healthy, Swedish mothers were analyzed by radioimmunologic method for content of bovine β‐lacto‐globulin. Detectable amounts (5‐800 μ/1) were found in 93 of 232 milk samples (40%). Six mothers had no detectable β‐lactoglobulin in their breast milk on any occasion. Two mothers had measurable /Mactoglobulin in all their milk samples. No correlation was found between daily cows milk intake and concentration of β‐lactoglobulin in the milk samples. Six mothers with allergic symptoms such as asthma, hay‐fever, eczema all had detectable amounts of β‐lactoglobulin in their milk. Of 19 mothers without allergy, 13 had detectable amounts. This difference did not show statistical significance. The presence of symptoms in the infant such as diarrhoea, vomiting, colic, exanthema was significantly correlated to high levels of β‐lactoglobulin in the milk. Bovine β‐lactoglobulin was also detected in 7 of 13 serum samples. The two mothers with detectable β‐lactoglobulin in all milk samples had the highest serum values, and their infants suffered from gastro‐intestinal symptoms, weight decline and exanthema.

Nondigestible carbohydrates in the diets of infants and young children: A commentary by the ESPGHAN Committee on Nutrition

The consumption of nondigestible carbohydrates is perceived as beneficial by health professionals and the general public, but the translation of this information into dietary practice, public health recommendations, and regulatory policy has proved difficult. Nondigestible carbohydrates are a heterogeneous entity, and their definition is problematic. Without a means to characterize the dietary components associated with particular health benefits, specific attributions of these cannot be made. Food labeling for “fiber” constituents can be given only in a general context, and the development of health policy, dietary advice, and education, and informed public understanding of nondigestible carbohydrates are limited. There have, however, been several important developments in our thinking about nondigestible carbohydrates during the past few years. The concept of fiber has expanded to include a range of nondigestible carbohydrates. Their fermentation, fate, and effects in the colon have become a defining characteristic; human milk, hitherto regarded as devoid of nondigestible carbohydrates, is now recognized as a source for infants, and the inclusion of nondigestible carbohydrates in the diet has been promoted for their “prebiotic” effects. Therefore, a review of the importance of nondigestible carbohydrates in the diets of infants and young children is timely. The aims of this commentary are to clarify the current definitions of nondigestible carbohydrates, to review published evidence for their biochemical, physiologic, nutritional, and clinical effects, and to discuss issues involved in defining dietary guidelines for infants and young children.

Prevalence of IgA-Antiendomysium and IgA-Antigliadin Autoantibodies at Diagnosis of Insulin-Dependent Diabetes Mellitus in Swedish Children and Adolescents

Objective. This study was conducted to investigate the prevalence of celiac disease (CD) in children and adolescents at diagnosis of insulin-dependent diabetes mellitus (IDDM) before insulin treatment was started. Material and Methods. At diagnosis of IDDM, and before treatment was started, 115 children and adolescents were screened for IgA- antiendomysium (EMA) and IgA-antigliadin antibodies (AGA). Those found to be EMA-positive and/or AGA-positive were investigated further with intestinal biopsy. Results. Of the 115 patients, 2 had known CD at diagnosis of IDDM; of the remainder of patients, 6% (7/113) were found to be EMA-positive and 9% (10/113) were found to have AGA levels above normal. Of the 6 patients who underwent biopsy, 5 manifested villous atrophy. In addition, 2 patients with high EMA and AGA antibody titers refused biopsy, and 4 patients with low EMA and/or AGA titers were found to have normal titers at control before biopsy decision. Conclusion. Because the prevalence of CD at diagnosis of IDDM would seem to be 6% to 8%, screening for CD seems to be justified among patients with newly diagnosed IDDM.

Macromolecular Absorption in Preterm and Term Infants

ABSTRACT. Human o‐lactalbumin (α‐LA) has been used as a marker for measuring macromolecular absorption. The serum concentration of human α‐LA after a human milk feed has been studied in 32 healthy very low birthweight infants (VLBW), fed human milk (gestational age 26–32 weeks) and in 56 term, breast‐fed infants, age 3–140 days. At 31 weeks of gestation the serum concentration of human α‐LA was more than 10 times higher (mean value 3000 and median value 2101 μg/1 serum/1 human milk/kg body weight, n= 11) than in the term infants aged 3–30 days (mean value 257 and median value 152, n= 29). The serum concentration of o‐LA decreased with increasing maturity in the VLBW‐infants. At a postconceptional age of 37 weeks the values were similar (mean value 200 and median value 99, n= 8) to those found for term infants during the first month. In the term infants a decreasing absorption of α‐LA was found with increasing postnatal age.

Protein intake in early infancy: effects on plasma amino acid concentrations, insulin metabolism, and growth

ABSTRACT: The effects of different protein intakes on wt gain, insulin secretion, and plasma concentrations of amino acids have been evaluated in a prospective study involving 30 normal term infants. The infants were studied from 4.0 to 6.0 mo of age. Ten infants were breast-fed (BF), the others were randomly divided into two groups of 10 infants. One group was fed a formula containing 1.3 g protein/100 mL (F 1.3), the other a formula with 1.8 g protein/100 mL (F 1.8). The formulas were isocaloric (72 kcaI/100 mL), and the fat concentrations were 3.5 g/100 mL (F 1.3) and 3.2 g/100 mL (F 1.8). AH infants received the same supplementary foods. The urinary C-peptide excretion in the infants fed the F 1.8-formula was 4.4 ± 2.1 nmol/mmol creatinine or 19.4 ± 12.9 nmol/m2, significantly higher than that in the infants fed the F 1.3-formula (2.6 ± 1 .5 and 7.9 ± 5.1) or the BF infants (1.7 ± 1.4 and 6.3 ± 6.0). Gain in wt was 18.0 ± 4.3,19.9 ± 3.9, 22.8 ± 1.6 g/kg/wk and corresponded to protein intakes of 1.3 ± 0.2, 1.9 ± 0.3, and 2.6 ± 0.2 g/kg/d, in the BF, F 1.3, and F 1.8 groups, respectively. Gain in length was 6.7 ± 1 .8 (BFgroup), 6.2 ± 2.5 (F 1.3-group), and 7.6 ± 2.2 (F 1.8- group) mm/m/wk. Wt gain correlated with urinary Cpeptide excretion at 6.0 mo (r=0.51, p<0.01) and with protein intake (r=0.43, p<0.01). Furthermore, protein intake correlated with urinary C-peptide excretion (r=0.66, p<0.001). Caloric intake from carbohydrate and fat correlated both with wt gain (r=0.34, p<0.05) and with urinary C-peptide (r=0.44, p<0.05). A higher protein intake during a meal resulted in a higher postprandial excretion of urinary C-peptide. The difference between plasma C-peptide (δC-peptide) before and after a meal was highest in the groups of infants fed the F 1.8-formula. The intakes of the insulin-releasing amino acids (arginine, lysine, leucine, phenylalanine, valine, isoleucine, and threonine) were higher in the F 1.8-group than in the F 1.3- and BF-groups. The sums of the fasting plasma concentrations of these amino acids were 64.8 (BF), 83.6 (F 1.3), and 96.3 (F 1.8) /µ nol/100 mL. The plasma concentrations of the branched-chain amino acids, valine, leucine, and isoleucine correlated with wt gain and plasma valine-glycine ratio increased with higher protein intake. These results suggest that protein amino acid-induced insulin secretion could be a factor promoting growth in infants on high protein intakes.

Preparation and Handling of Powdered Infant Formula: A Commentary by the ESPGHAN Committee on Nutrition.

Powdered infant formulae are not sterile and may contain pathogenic bacteria. In addition, milk products are excellent media for bacterial proliferation. Multiplication of Enterobacter sakazakii in prepared formula feeds can cause devastating sepsis, particularly in the first 2 months of life. In approximately 50 published case reports of severe infection, there are high rates of meningitis, brain abscesses and necrotizing enterocolitis, with an overall mortality from 33% to 80%. Breast feeding provides effective protection against infection, one of the many reasons why it deserves continued promotion and support. To minimize the risk of infection in infants not fully breastfed, recommendations are made for preparation and handling of powdered formulae for children younger than 2 months of age. In the home setting, powdered infant formulae should be freshly prepared for each feed. Any milk remaining should be discarded rather than used in the following feed. Infant feeds should never be kept warm in bottle heaters or thermoses. In hospitals and other institutions written guidelines for preparation and handling of infant formulae should be established and their implementation monitored. If formula needs to be prepared in advance, it should be prepared on a daily basis and kept at 4 degrees C or below. Manufacturers of infant formulae should make every effort to minimize bacterial contamination of powdered products.