Weaning practices in phenylketonuria vary between health professionals in Europe

Background

In phenylketonuria (PKU), weaning is considered more challenging when compared to feeding healthy infants. The primary aim of weaning is to gradually replace natural protein from breast milk or standard infant formula with solids containing equivalent phenylalanine (Phe). In addition, a Phe-free second stage L-amino acid supplement is usually recommended from around 6 months to replace Phe-free infant formula. Our aim was to assess different weaning approaches used by health professionals across Europe.

Methods

A cross sectional questionnaire (survey monkey®) composed of 31 multiple and single choice questions was sent to European colleagues caring for inherited metabolic disorders (IMD). Centres were grouped into geographical regions for analysis.

Results

Weaning started at 17–26 weeks in 85% (n = 81/95) of centres, >26 weeks in 12% (n = 11/95) and < 17 weeks in 3% (n = 3/95). Infant's showing an interest in solid foods, and their age, were important determinant factors influencing weaning commencement. 51% (n = 48/95) of centres introduced Phe containing foods at 17–26 weeks and 48% (n = 46/95) at >26 weeks. First solids were mainly low Phe vegetables (59%, n = 56/95) and fruit (34%, n = 32/95).

A Phe exchange system to allocate dietary Phe was used by 52% (n = 49/95) of centres predominantly from Northern and Southern Europe and 48% (n = 46/95) calculated most Phe containing food sources (all centres in Eastern Europe and the majority from Germany and Austria). Some centres used a combination of both methods.

A second stage Phe-free L-amino acid supplement containing a higher protein equivalent was introduced by 41% (n = 39/95) of centres at infant age 26–36 weeks (mainly from Germany, Austria, Northern and Eastern Europe) and 37% (n = 35/95) at infant age > 1y mainly from Southern Europe. 53% (n = 50/95) of centres recommended a second stage Phe-free L-amino acid supplement in a spoonable or semi-solid form.

Conclusions

Weaning strategies vary throughout European PKU centres. There is evidence to suggest that different infant weaning strategies may influence longer term adherence to the PKU diet or acceptance of Phe-free L-amino acid supplements; rendering prospective long-term studies important. It is essential to identify an effective weaning strategy that reduces caregiver burden but is associated with acceptable dietary adherence and optimal infant feeding development.

Early feeding practices in infants with phenylketonuria across Europe

Background

In infants with phenylketonuria (PKU), dietary management is based on lowering and titrating phenylalanine (Phe) intake from breast milk or standard infant formula in combination with a Phe-free infant formula in order to maintain blood Phe levels within target range. Professionals use different methods to feed infants with PKU and our survey aimed to document practices across Europe.

Methods

We sent a cross sectional, survey monkey® questionnaire to European health professionals working in IMD. It contained 31 open and multiple-choice questions. The results were analysed according to different geographical regions.

Results

Ninety-five centres from 21 countries responded. Over 60% of centres commenced diet in infants by age 10 days, with 58% of centres implementing newborn screening by day 3 post birth. At diagnosis, infant hospital admission occurred in 61% of metabolic centres, mainly in Eastern, Western and Southern Europe. Breastfeeding fell sharply following diagnosis with only 30% of women still breast feeding at 6 months.

53% of centres gave pre-measured Phe-free infant formula before each breast feed and 23% alternated breast feeds with Phe-free infant formula. With standard infant formula feeds, measured amounts were followed by Phe-free infant formula to satiety in 37% of centres (n = 35/95), whereas 44% (n = 42/95) advised mixing both formulas together. Weaning commenced between 17 and 26 weeks in 85% centres, ≥26 weeks in 12% and < 17 weeks in 3%.

Discussion

This is the largest European survey completed on PKU infant feeding practices. It is evident that practices varied widely across Europe, and the practicalities of infant feeding in PKU received little focus in the PKU European Guidelines (2017). There are few reports comparing different feeding techniques with blood Phe control, Phe fluctuations and growth. Controlled prospective studies are necessary to assess how different infant feeding practices may influence longer term feeding development.

Monensin and a blend of castor oil and cashew nut shell liquid used in a high-concentrate diet abruptly fed to Nellore cattle

Monensin and functional oils (FO) were supplemented to a high-concentrate diet abruptly fed to 12 ruminally cannulated Zebu steers to study their effects on rumen fermentation, blood metabolites, and , , and relative population. A randomized complete block design with repeated measures over time within 2 experimental periods of 21 d each was used. Treatments were a control (CTR; with no additives), FO (included at 400 mg/kg), and monensin included at 30 mg/kg (M30) or 40 mg/kg (M40). All steers were fed the same high-concentrate basal diet, which consisted of 92.25% concentrate. The first 60 h after transition showed a treatment and hour interaction for ruminal propionate proportion ( = 0.028), and no change in acetate molar proportion ( = 0.633), rumen pH ( = 0.370), and time the rumen pH remained below 5.6 ( = 0.242) were observed. The acetate:propionate ratio decreased ( = 0.020) when monensin was fed in both concentrations (2.30 for the M30 treatment and 2.32 for the M40 treatment) compared with when the CTR was fed (2.85), without being different when the FO (2.71) treatment was fed. Only the M30 treatment did not show pH below 5.2 (P=0.047) over the 60 h after the abrupt transition. Within the entire period, DMI ( = 0.008) and mean ruminal pH ( = 0.040) as well as molar proportions of propionate ( = 0.034) and valerate ( = 0.031) had significant interactions between treatment and day. Total VFA concentration was greater ( = 0.017) for the M30 (117.36 m) and CTR treatments (115.77 m) compared with the M40 treatment (105.02 m), without being different for the FO treatment (111.55 m). Treatments did not change feed behavior parameters. Blood HCO ( = 0.006) and total carbon dioxide ( = 0.003) were greater for the M30 (27.8 and 29.3 mmol/L, respectively) and FO treatments (28.3 and 29.7 mmol/L, respectively) compared with the CTR treatment (25.7 and 26.9 mmol/L, respectively). ( < 0.0001) and ( < 0.0001) decreased their population throughout days, whereas ( = 0.026) increased its population. Independent of ciliated protozoa genera, the greatest ( < 0.0001) protozoa counts were observed for the CTR treatment (52.7 × 10/mL), intermediate for the FO treatment (35.3 x10/mL), and least for steers fed monensin in both concentrations (15 × 10/mL for the M30 treatment and 14 × 10/mL for the M40 treatment). Feed additives had different effects to reduce the subacute acidosis. The use of the FO and M40 treatments did not change most of the rumen fermentation variables, especially in the first week after abrupt transition, when the M30 treatment provided higher protection against acidosis.