Nataša Fidler Mis

Complementary Feeding: A Position Paper by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Committee on Nutrition

ABSTRACT This position paper considers different aspects of complementary feeding (CF), focussing on healthy term infants in Europe. After reviewing current knowledge and practices, we have formulated these recommendations: Timing: Exclusive or full breast-feeding should be promoted for at least 4 months (17 weeks, beginning of the 5th month of life) and exclusive or predominant breast-feeding for approximately 6 months (26 weeks, beginning of the 7th month) is a desirable goal. Complementary foods (solids and liquids other than breast milk or infant formula) should not be introduced before 4 months but should not be delayed beyond 6 months. Content: Infants should be offered foods with a variety of flavours and textures including bitter tasting green vegetables. Continued breast-feeding is recommended alongside CF. Whole cows’ milk should not be used as the main drink before 12 months of age. Allergenic foods may be introduced when CF is commenced any time after 4 months. Infants at high risk of peanut allergy (those with severe eczema, egg allergy, or both) should have peanut introduced between 4 and 11 months, following evaluation by an appropriately trained specialist. Gluten may be introduced between 4 and 12 months, but consumption of large quantities should be avoided during the first weeks after gluten introduction and later during infancy. All infants should receive iron-rich CF including meat products and/or iron-fortified foods. No sugar or salt should be added to CF and fruit juices or sugar-sweetened beverages should be avoided. Vegan diets should only be used under appropriate medical or dietetic supervision and parents should understand the serious consequences of failing to follow advice regarding supplementation of the diet. Method: Parents should be encouraged to respond to their infants hunger and satiety queues and to avoid feeding to comfort or as a reward.

Arsenic in Rice: A Cause for Concern

ABSTRACT Inorganic arsenic intake is likely to affect long-term health. High concentrations are found in some rice-based foods and drinks widely used in infants and young children. In order to reduce exposure, we recommend avoidance of rice drinks for infants and young children. For all of the rice products, strict regulation should be enforced regarding arsenic content. Moreover, infants and young children should consume a balanced diet including a variety of grains as carbohydrate sources. Although rice protein–based infant formulas are an option for infants with cows’ milk protein allergy, the inorganic arsenic content should be declared and the potential risks should be considered when using these products.

ESPGHAN Committee on Nutrition Position Paper. Intravenous Lipid Emulsions and Risk of Hepatotoxicity in Infants and Children : a Systematic Review and Meta-analysis

ABSTRACT The aim of the present article was to perform a systematic review with meta-analysis of available scientific evidence regarding the role of different intravenous lipid emulsions (ILE) in the pathogenesis of cholestasis and parenteral nutrition–associated liver disease. A systematic review of the literature (up to March 2015) identified 23 randomized controlled trials (RCTs). Of these, 17 were performed in preterm infants or critically ill neonates with a short duration of intervention, 2 in older children with short-term use (following surgery or bone marrow transplantation), 1 in neonates with long-term use, and 3 in infants and children receiving long-term parenteral nutrition (PN). Meta-analysis showed no differences in the rate of cholestasis or bilirubin levels associated with short-term use of different ILEs. Because of high heterogeneity of the long-term studies no meta-analysis could be performed. Available studies found that the use of multicomponent fish oil (FO)-containing ILE compared with pure soya bean oil (SO), ILE-reduced liver enzymes, and bilirubin levels in noncholestatic children on long-term PN and one other RCT found that FO-based ILE-reversed cholestasis in a proportion of patients. The ESPGHAN Committee on Nutrition concludes that there is no evidence of a difference in rates of cholestasis or bilirubin levels between different ILE for short-term use in neonates. The use of multicomponent FO-containing ILE may contribute to a decrease in total bilirubin levels in children with IF on prolonged PN. Well-designed RCTs are, however, lacking and long-term effects have not been determined.

Under- and over-reporting of energy intake in slovenian adolescents.

OBJECTIVE To examine under- and over-reporting of energy intake (EI) among adolescents and to compare relative food and nutrient intakes of under-reporters (UR), over-reporters (OR), and the whole population to acceptable reporters (AR). DESIGN All adolescents completed food frequency questionnaires at regional health centers, and a subgroup also completed a 3-day weighed dietary protocol at home. SETTING This study is a part of the first national representative study on dietary habits of Slovenian adolescents. PARTICIPANTS In total, 2,813 adolescents entering high school (10% of the population); participation rate was 95%. MAIN OUTCOME MEASURES Absolute EI and relative intakes of food and nutrients. ANALYSIS Prodi (version 5.2 expert plus, Nutri-Science, Stuttgart, Germany, 2004) software was used to evaluate dietary intakes; t test, analysis of variance, and Mann-Whitney testing were used for differences between means, and chi-square was used for differences between proportions. Level of significance was set at P = .05. RESULTS The prevalence of UR and OR was 34% and 10% among boys, and 27% and 11% among girls. Under-reporters reported lower energy percentage from carbohydrates, higher energy percentage from fats and proteins, and higher micronutrient densities than AR. CONCLUSIONS AND IMPLICATIONS Under-reporting and over-reporting are widespread among Slovenian adolescents. Exclusion of UR and OR does not influence mean value of EI when assessing the diet of a group as a whole.

Dietary intake of macro- and micronutrients in Slovenian adolescents: comparison with reference values.

Background: Data on a nationally representative dietary intake in Central Europe is lacking. We investigated the diet of adolescents in Slovenia. Methods: Dietary habits were assessed using a food frequency questionnaire (n = 2,661), and present nutrition was assessed using a 3-day weighted dietary protocol (n = 197) for validation purposes. Dietary intake was calculated and compared with Central European [German (D), Austrian (A), and Swiss (CH); D-A-CH] recommendations and World Health Organization/Food and Agriculture Organization (WHO/FAO) recommendations. Results: Adolescents consumed exceeding reference intake values of free sugars (boys 16% of energy, girls 17%), saturated fatty acids (SFA; 13% of energy), and sodium (boys 203%, girls 210% of the WHO/FAO upper limit), but below-reference intake values of polyunsaturated fatty acids (PUFA; boys 5% of energy; girls 6%), water (boys 1,786 ml/day, girls 2,016 ml/day), and fiber density (only girls 2.8 g/MJ, p < 0.001). Among micronutrients, below-reference intakes (% of D-A-CH: boys and girls, respectively, p < 0.05) were reported for folate (64 and 69%), fluoride (28 and 31%), and calcium (91 and 97%), as well as for vitamin D (20 and 20%). Conclusions: The dietary habits of Slovenian adolescents are less than optimal. They are characterized by exceeding reference intake values of free sugars, salt, and SFA, and a below-reference intake of PUFA, water, and several micronutrients.

Food intake in Slovenian adolescents and adherence to the Optimized Mixed Diet: a nationally representative study

OBJECTIVES To investigate the food intake of Slovenian adolescents and to compare it with food-based dietary guidelines developed for children and adolescents, named the Optimized Mixed Diet (OMD). The OMD is a useful tool for the evaluation of food intake of adolescents. DESIGN All adolescents completed an FFQ at a regional health centre; a subgroup also completed a 3 d weighed dietary protocol at home. SETTING This study is a part of the first national representative study on the dietary habits of Slovenian adolescents. SUBJECTS This cross-sectional study included a representative sample of 2813 Slovenian adolescents entering high school, aged 14-17 years, from all ten geographical regions of Slovenia. RESULTS The greatest deviations from the recommended intakes of the main food groups in the OMD were significantly lower intakes of (P < 0·001, mean): vegetables (179 and 163 g/d in boys and girls, respectively), bread/cereals (271 and 226 g/d), potatoes/rice/pasta (212 and 163 g/d); in boys also a significantly lower intake of fruits (mean: 321 g/d, P < 0·001) and a significantly higher intake of meat/meat products (mean: 126 g/d, P < 0·001). Additionally, the results show too high intake of sugar-sweetened beverages and too low intakes of fish and plant oils in both genders. CONCLUSIONS The food intake pattern of Slovenian adolescents deviates markedly from a healthy eating pattern. Nutrition education and interventions are needed for Slovenian adolescents.

Adequate iodine intake of Slovenian adolescents is primarily attributed to excessive salt intake

In Slovenia, table salt iodization has been applied to combat iodine deficiency. Recently, we found that Slovenian adolescents attained iodine sufficiency (median urinary iodine concentration was 140 microg/L; prevalence of goiter was <1%). National data indicate that salt intake of Slovenian population is too high (150% above the recommended limit); therefore, we hypothesized that sufficient iodine intake in adolescents can be primarily attributed to excessive salt intake. In a cross-sectional study, we investigated iodine and salt intake in Slovenian adolescents as well as the contributions of different foods to their intake. We determined the iodine and salt intake of a national representative sample of 2581 adolescents, aged 14 to 17 years, using the Food Frequency Questionnaire (FFQ). The FFQ covered habitual diets over the past year, and 2485 (96%) adolescents completed a valid FFQ (1370 girls, 1115 boys). The iodine intake was 189.7 +/- 2.6 microg/d (mean +/- standard error of mean), well above the recommended 150 microg/d (P < .001). Table salt was by far the biggest dietary source of iodine and sodium for both sexes. Total salt intake (mean +/- standard error of mean, 10.4 +/- 0.2 g/d) significantly exceeded the upper World Health Organization limit (<5 g/d, P < .001), especially in boys (11.5 +/- 0.3 vs 9.4 +/- 0.2 g/d in girls, P < .001). The main food sources of salt were table salt (33%), bread (24%), salty snack products (10%), meat products (8%), fish products (6%), and milk (4%). Salt intake from foods, excluding table salt, was 6.9 g/d (67% of total salt intake). We conclude that although Slovenian adolescents are iodine sufficient, their salt intake, especially among boys, is too high. Several nutritional interventions are proposed to reduce total salt intake while ensuring adequate iodine intake.

European Society for Paediatric Gastroenterology, Hepatology and Nutrition Guidelines for the Evaluation and Treatment of Gastrointestinal and Nutritional Complications in Children With Neurological Impairment

OBJECTIVES Feeding difficulties are frequent in children with neurological impairments and can be associated with undernutrition, growth failure, micronutrients deficiencies, osteopenia, and nutritional comorbidities. Gastrointestinal problems including gastroesophageal reflux disease, constipation, and dysphagia are also frequent in this population and affect quality of life and nutritional status. There is currently a lack of a systematic approach to the care of these patients. With this report, European Society of Gastroenterology, Hepatology and Nutrition aims to develop uniform guidelines for the management of the gastroenterological and nutritional problems in children with neurological impairment. METHODS Thirty-one clinical questions addressing the diagnosis, treatment, and prognosis of common gastrointestinal and nutritional problems in neurological impaired children were formulated. Questions aimed to assess the nutritional management including nutritional status, identifying undernutrition, monitoring nutritional status, and defining nutritional requirements; to classify gastrointestinal issues including oropharyngeal dysfunctions, motor and sensory function, gastroesophageal reflux disease, and constipation; to evaluate the indications for nutritional rehabilitation including enteral feeding and percutaneous gastrostomy/jejunostomy; to define indications for surgical interventions (eg, Nissen Fundoplication, esophagogastric disconnection); and finally to consider ethical issues related to digestive and nutritional problems in the severely neurologically impaired children. A systematic literature search was performed from 1980 to October 2015 using MEDLINE. The approach of the Grading of Recommendations Assessment, Development, and Evaluation was applied to evaluate the outcomes. During 2 consensus meetings, all recommendations were discussed and finalized. The group members voted on each recommendation using the nominal voting technique. Expert opinion was applied to support the recommendations where no randomized controlled trials were available.

Iodine Intake of Slovenian Adolescents

Background: Slovenia is classified as being iodine-deficient. We recently found that Slovenian adolescents are iodine-sufficient (median urinary iodine concentration of the population 140 µg/l) and the prevalence of goiter is low (0.9%). The objective of this study was to evaluate iodine intake, the prevalence of marginal, low and excessive intake (<50, 50–100 and ≧300 µg/day), as well as the main sources of iodine in the diet of Slovenian adolescents. Methods: A cross-sectional study included 2,581 adolescents (1,415 girls, 1,166 boys, mean age ± SD 15.6 ± 0.5 years) representing 10% of 15-year-old Slovenian adolescents. Iodine intake was determined using a food frequency questionnaire (FFQ) in the whole population studied (n = 2,485) and weighted 3-day dietary protocols (3DPs) in a subgroup of participants (n = 191). Results: Median iodine intake determined from FFQ was 155.8 µg/day. There was no significant difference between genders. Marginal, low and excessive iodine intake was observed in 3.3, 20.3 and 11.3% of the adolescents, respectively. The major food sources of dietary iodine included table salt (39 % of the mean daily iodine intake), beverages (22%) and milk/milk products (19%). Conclusions: Dietary iodine intake in Slovenian adolescents is adequate, illustrating the effective salt iodization program.

Prevention of Vitamin K Deficiency Bleeding in Newborn Infants : A Position Paper by the ESPGHAN Committee on Nutrition

ABSTRACT Vitamin K deficiency bleeding (VKDB) due to physiologically low vitamin K plasma concentrations is a serious risk for newborn and young infants and can be largely prevented by adequate vitamin K supplementation. The aim of this position paper is to define the condition, describe the prevalence, discuss current prophylaxis practices and outcomes, and to provide recommendations for the prevention of VKDB in healthy term newborns and infants. All newborn infants should receive vitamin K prophylaxis and the date, dose, and mode of administration should be documented. Parental refusal of vitamin K prophylaxis after adequate information is provided should be recorded especially because of the risk of late VKDB. Healthy newborn infants should either receive 1 mg of vitamin K1 by intramuscular injection at birth; or 3 × 2 mg vitamin K1 orally at birth, at 4 to 6 days and at 4 to 6 weeks; or 2 mg vitamin K1 orally at birth, and a weekly dose of 1 mg orally for 3 months. Intramuscular application is the preferred route for efficiency and reliability of administration. The success of an oral policy depends on compliance with the protocol and this may vary between populations and healthcare settings. If the infant vomits or regurgitates the formulation within 1 hour of administration, repeating the oral dose may be appropriate. The oral route is not appropriate for preterm infants and for newborns who have cholestasis or impaired intestinal absorption or are too unwell to take oral vitamin K1, or those whose mothers have taken medications that interfere with vitamin K metabolism. Parents who receive prenatal education about the importance of vitamin K prophylaxis may be more likely to comply with local procedures.