Nestle Nutrition workshop series. Paediatric programme最新文献

Whilst growth and its derangement in disease have been a long-standing focus in pediatrics, increasing evidence points to a further, fundamental role of early growth in the programming of later health. In studies on animals and humans, rapid early growth is associated with higher risk of obesity and cardiovascular disease, and in animals, senescence and life span - a concept encapsulated in the postnatal growth acceleration hypothesis. This hypothesis explains the benefits of breastfeeding to infants for reduced cardiovascular disease risk in terms of their slower early growth and the fetal origins hypothesis in terms of the adverse postnatal catch-up growth in infants born small. Early growth, notably prior to full term, also influences brain development and cognition - and emerging evidence suggests diverse, broader effects, for instance cancer and the onset of puberty. Understanding the mechanisms, triggers and windows for such effects is important, given the major public health implications, including potential new opportunities for primary prevention of adult disease.

Marketing-driven innovation in the field of pediatric nutrition, in particular in the infant formula segment is not sustainable. New benefits of products must be scientifically proven and safety and efficacy of new formulae established in clinical trials. The scientific innovation process of three infant formulae is described. Improvement in protein quality allowed to reduce the protein concentration in whey-based infant formula. Weight gain and BMI of infants fed those formulae corresponds to breastfed infants and is lower than in infants fed traditional formulae with higher protein concentration. A meta-analysis indicates associations between rapid weight gain in infancy and obesity later in life. If infants cannot be exclusively breastfed until 4-6 months of age, feeding low-protein formulae may contribute to positive long-term health outcome with potentially important health economic effects. A partially hydrolyzed whey based formula for prevention of allergic symptoms in children with hereditary risk for allergic diseases was developed more than 25 years ago. The most recent meta-analysis which included 15 randomized clinical trials indicates that the risk of all allergic diseases and atopic dermatitis/eczema is significantly reduced in infants at risk when the partially hydrolyzed formula is fed. The partially hydrolyzed formula had the same protective effect as casein-based high-degree extensively hydrolyzed formula. Because of substantial price differences between the two formulae, feeding the partially hydrolyzed whey formula is cost saving. Hypoallergenic claims can be made in many countries, and international nutrition committees have positively commented the preventive effect of those formulae. Acidified formulae have been widely used during the last decade in replacement feeding programs for infants whose mothers are HIV positive. The formula was innovated by improving whey protein quality and lowering protein concentration. The bacteriostatic properties of the new formula were proven in in vitro tests. Meta-analysis indicated that feeding the formula to immunocompromised infants resulted in growth similar to breastfeeding. The bacteriostatic effects of the acidified formula need to be communicated to health care professionals, but also the risks if replacement feeding is not acceptable, feasible, affordable, sustainable, and safe for mother and infant.

A clear relationship exists between undernutrition, poorer growth and poor development in term and preterm infants. However, preterm infants are at greater risk than term infants. Undernutrition is more common and 'programmed' growth rates are almost six times faster. Thus, even short periods of nutritional deprivation may have significant effects. Recent advances have led to an improvement in early growth but very low birthweight infants remain small for gestational age at hospital discharge. Studies suggest that a 'window of opportunity' exists after hospital discharge, in that better growth between discharge and 2-3 months corrected age is paralleled by better development, and poorer growth is associated with poorer development. However, interventions aimed at improving growth and development have yielded varying results. This may partly be related to differences in study design as well as the composition of the nutrient-enriched formulas. Irrespective, one point is concerning, i.e. infant boys appear to be at a developmental disadvantage when fed a term infant formula after discharge. A single study has also suggested that dietary intervention can improve brain growth in term and preterm infants with perinatal brain injury. However, concern has been expressed about rapid 'catch-up' growth in preterm infants and the development of insulin resistance and visceral adiposity. Data from our group do not support the idea of increased or altered adiposity in preterm infants fed a nutrient-enriched formula after hospital discharge.

Early childhood growth failure is a significant public health problem in developing countries. We examine relationships between low birthweight and stunting with child development. Compared to children born with normal birthweight, low birth-weight children have substantially poorer cognitive and schooling outcomes later in life. Linear growth failure leading to stunting mostly occurs before age 2 years, with stunting in older children reflecting growth failure in early life. Many studies show that stunting is associated with poor mental and motor development in infants and with low scores in cognitive tests, increased frequency of behavioral problems and poor school achievement in older children. Very few studies have assessed the relative importance for development of prenatal vs. postnatal growth failure and even fewer have done so using appropriate statistical techniques. The limited evidence to date suggests growth during the first 2 years of life is more important than growth at any other time, including the prenatal period, for predicting later cognitive development, schooling and educational achievement. In conclusion, children in settings of poverty who experience growth failure prior to age 2 years have reduced potential to succeed in school and to be productive members of society.

Exclusively breastfed (EBF) infants have higher weight gain during the first 2 months, and lower thereafter. The explanation for this phenomenon is not clear. Longitudinal data from the Social Medical Survey of Children Attending Child Health Clinics study with a cohort of 2,151 Dutch children were analyzed according to a pattern mixture model. It appears that higher than average growth of EBF infants during the first 2 months is primarily attributable to selective dropout. Furthermore, between months 2 and 6, light nonEBF infants gain more weight than light EBF infants. Both factors aid in explaining differences in growth between EBF and nonEBF infants. The WHO Child Growth Standards for weight-for-age have been calculated from a subgroup of 903 infants (out of 1,743) that complied with strict feeding criteria. If similar dropout mechanisms operate in the Multicentre Growth Reference Study, then the WHO weight-for-age standards are expected to be systematically different from those for the entire group of 1,743 infants.

During the past decade, the use of claims became more and more important in many countries in relation to the increased awareness of consumer about the link between foods and health, offering to industry a valuable opportunity to differentiate and valorize their products and to promote innovation. However, more and more stringent regulations are developed, all based on the general principles adopted by the Codex Alimentarius Commission. In addition to the different regulatory processes and administrative requirements according to the country, the high level (and cost) of scientific substantiation of claims, the constraints introduced by nutrient profiles and the poor knowledge of the impact on consumer depending on the cultural contexts may limit these opportunities or, at least complicate their use. All these issues are briefly analyzed, highlighting some striking convergences and differences between countries.

It is particularly important that in areas of strategic public health significance, e.g. infant feeding, the processes used to extract robust scientific findings are timely, rigorous and transparent. Low rates of breastfeeding, poor weaning practices and variability within and between countries have been reported by many authors and resulted in a call for more consistency of recommendations across regions. The adoption of consumer behaviors in line with recommendations is of course not guaranteed. The consumers in this instance are both the infant and their mother or other carers. As infants completely depend on their carers to make food choices for them, it is important that they understand nutrition, and the importance of food choices for health of the baby and in future life. Parents obtain information from a variety of sources, the quality of which may vary, and is not necessarily evidence-based. Although carers decide what is offered or withheld, the infant may contribute to this decision by expressing dissatisfaction or refusing food. At the heart of all feeding choices lies this interplay between carer and child, influenced by the environment at household, community and societal level.

Numerous epidemiological studies suggest that there is an inverse relationship between allergic diseases and infections in early childhood, but there are also several well-conducted epidemiological studies that seemingly contradict this relationship. The maturation of the immature immune regulation after birth is largely driven by exposure to microbes. Germ-free animals manifest excessive immune responses when immunized and they do not develop normal immune regulation. The controversy regarding the role of infections for subsequently developing allergy is partly due to varying clinical definitions of 'allergy'. Thus, wheezing and asthma have often been included as outcomes. The hypothesis that commensal microbes are the normal stimulants for the maturation towards a balanced immune response is relevant for IgE-mediated disease manifestations, rather than recurrent bronchial obstruction per se. Epidemiological, clinical and animal studies taken together suggest that broad exposure to a wealth of commensal, non-pathogenic microorganisms early in life are associated with protection, not only against IgE-mediated allergies, but also conceivably against type-1 diabetes and inflammatory bowel disease. This has little relationship with 'hygiene' in the usual meaning of the word. The term 'hygiene hypothesis' is unfortunate, as it is misleading. A better term would be 'microbial deprivation hypothesis'.

The hygiene hypothesis proposes that the growing epidemic of atopic eczema, allergic rhinoconjunctivitis and asthma is related to reduced exposure to microbes at an early age as a result of environmental changes in the industrialized world. These include improved sanitation and living conditions, vaccinations and antimicrobial therapy, together with declining family size and changes in dietary intake. Recent scientific advances demonstrate that the hygiene hypothesis needs to be extended in three respects. Firstly, rigorous research in the field of probiotics points to the importance of the collective composition and the compositional development of the gut microbiota in consolidation of healthy immune responsiveness. Secondly, immunomodulatory and suppressive immune responses have been shown to complement the original immunological basis of the hygiene hypothesis, the so-called T helper 1/T helper 2 paradigm. Thirdly, host-microbe interaction appears to affect the risk of developing not only atopic disease but also other inflammatory Western lifestyle diseases, including obesity. The results of experimental studies suggest that deviations in gut microbiota composition predispose to excessive energy storage and obesity, and, more recently in humans, aberrant compositional development of the gut microbiota has been shown to precede overweight, inviting enormous possibilities to reach preventive and therapeutic applications in weight management.