American Academy of Pediatrics: The use and misuse of fruit juice in pediatrics

Development of a diet-lifestyle quality index for young children and its relation to obesity: the Preschoolers Diet-Lifestyle Index

OBJECTIVE

To develop an index that assesses the degree of adherence to existing diet-lifestyle recommendations for preschoolers (Preschoolers Diet-Lifestyle Index (PDL-Index)) and to investigate its association with obesity.

DESIGN

The PDL-Index was constructed using eleven components (i.e. questions regarding the frequency of consumption of selected foods/food groups, time spent on television watching and on moderate-to-vigorous physical activities).

SETTING

Scores from 0 to 4 were assigned to all components of the index. The PDL-Index total score ranged from 0 to 44. Higher values of the PDL-Index indicate greater adherence to dietary and lifestyle recommendations for preschoolers or otherwise greater adherence to healthier dietary-lifestyle patterns.

SUBJECTS

As a validation procedure, a sample of 2287 preschoolers from Greece (GENESIS study) was used.

RESULTS

The participants following healthier diet-lifestyle patterns (third tertile of PDL-Index) were less likely to be obese or overweight/obese compared to those following unhealthy diet-lifestyle patterns (first tertile of PDL-Index). It was observed that a 1/44 unit increase in the score of the PDL-Index was associated with approximately 5 % and 3 % lower odds of being obese and overweight/obese, respectively. Statistically significant results were observed after adjusting for potential confounders.

CONCLUSIONS

The suggested PDL-Index could help public health policy makers in identifying vulnerable population subgroups and developing cost-effective, targeted intervention actions both in family and preschool settings. In addition, health-care professionals can use the PDL-Index to evaluate diet quality, lifestyle and risk for overweight/obesity at an individual level and counsel parents accordingly.

Girls' early sweetened carbonated beverage intake predicts different patterns of beverage and nutrient intake across childhood and adolescence

BACKGROUND

Information is limited on persistence of early beverage patterns throughout childhood and adolescence and their influence on long-term dietary intake.

OBJECTIVE

To describe changes in beverage intake during childhood and assess beverage and nutrient intake from ages 5 to 15 years among girls who were consuming or not consuming sweetened carbonated beverages (soda) at age 5 years.

DESIGN/SUBJECTS

Participants were part of a longitudinal study of non-Hispanic white girls and their parents (n=170) assessed biennially from age 5 to 15 years starting fall 1996.

STATISTICAL ANALYSES

At each assessment, intakes of beverages (milk, fruit juice, fruit drinks, soda, and tea/coffee), energy, macronutrients, and micronutrients were assessed using three 24-hour recalls. Analyses of longitudinal changes and the interaction between beverage type and age were conducted using a mixed modeling approach. Girls were categorized as either soda consumers or nonconsumers at age 5 years. A mixed modeling approach was used to assess longitudinal differences and patterns of change in beverage and nutrient intake between soda consumption groups.

RESULTS

Early differences in soda intake were predictive of later soda and milk intake and of differences in selected nutrients. Relative to girls who were not consuming soda beverages at age 5 years, soda consumers at age 5 years had higher subsequent soda intake, lower milk intake, higher intake of added sugars, lower protein, fiber, vitamin D, calcium, magnesium, phosphorous, and potassium from ages 5 to 15 years.

CONCLUSIONS

Soda consumption at age 5 years predicted patterns of nutrient intake that persisted during childhood and into adolescence. Diets of soda consumers were higher in added sugars and lower in protein, fiber, calcium, vitamin D, magnesium, phosphorous, and potassium. Findings provide a more complex picture regarding the emergence of early beverage patterns and their predictive effects on nutrient intake across childhood and adolescence.

Scurvy: forgotten but definitely not gone

Scurvy, a disease of vitamin C deficiency, is purportedly rare in the United States yet frequently may be misdiagnosed. Presenting symptoms include bone pain, limping, rashes, or spongy bleeding gingiva. These symptoms mimic many other disorders, which often results in numerous unnecessary, invasive, and expensive procedural investigations. The strongest indication of a scurvy diagnosis is the dramatic response to the administration of vitamin C. This case report demonstrates the complexities involved in determining the cause of one child's symptoms. A thorough nutritional history and a shrewd clinician are essential to the early diagnosis and treatment of scurvy.

Beverage intake of girls at age 5 y predicts adiposity and weight status in childhood and adolescence

BACKGROUND

Increased consumption of sweetened beverage has been linked to higher energy intake and adiposity in childhood.

OBJECTIVE

The objective was to assess whether beverage intake at age 5 y predicted energy intake, adiposity, and weight status across childhood and adolescence.

DESIGN

Participants were part of a longitudinal study of non-Hispanic white girls and their parents (n = 170) who were assessed biennially from age 5 to 15 y. At each assessment, beverage intake (milk, fruit juice, and sweetened beverages) and energy intake were assessed by using three 24-h recalls. Percentage body fat and waist circumference were measured. Height and weight were measured and used to calculate body mass index. Multiple regression analyses were used to predict the girls' adiposity. In addition, at age 5 y, girls were categorized as consuming <1, > or =1 and <2, or > or =2 servings of sweetened beverages. A mixed modeling approach was used to assess longitudinal differences and patterns of change in sweetened beverage and energy intake, adiposity, and weight status by frequency of sweetened beverage intake.

RESULTS

Sweetened beverage intake at age 5 y, but not milk or fruit juice intake, was positively associated with adiposity from age 5 to 15 y. Greater consumption of sweetened beverages at age 5 y (> or =2 servings/d) was associated with a higher percentage body fat, waist circumference, and weight status from age 5 to 15 y.

CONCLUSION

These findings provide new longitudinal evidence that early intake of sweetened beverages predicts adiposity and weight status across childhood and adolescence.

Weighing risk: the expert committee's recommendations in practice

In 2005, an expert committee was convened on behalf of the American Medical Association, the Health Resources and Service Administration, and the Centers for Disease Control and Prevention to update the previous recommendations on the evaluation and treatment of childhood obesity. Fifteen national health care organizations, which served children, participated in writing these recommendations. This article reviews recommendations on assessment of BMI, nutrition and activity, and obesity-related comorbidities. Principles of obesity prevention and treatment are discussed and high-risk eating and activity behaviors are addressed. Prevention and treatment of obesity are reviewed as set in the context of the Medical Home using the principles of the chronic disease model. The stepwise approach to obesity treatment and prevention is reviewed along with specific evidence-based/informed strategies. The skills needed to implement the recommendations, such as integration of the care team, roles and training, links to the health care system, connection to the community, and the role of the subspecialist, are discussed.

Can pure fruit and vegetable juices protect against cancer and cardiovascular disease too? A review of the evidence

While it is widely accepted that fruit and vegetables (F&V) lower the risk of cancer, and cardiovascular disease (CVD), the role of pure fruit and vegetable (PFV) juices is often downplayed. This review poses two questions: Are the protective benefits of F&V dependent upon constituents lacking in PFV juices (e.g. fibre)? Do PFV juices impact on disease risk when considered separately from F&V? Studies comparing the effects of fibre and antioxidants were reviewed, yielding the finding that the impact of F&V may relate more strongly to antioxidants, than to fibre. For the second question, high-quality published studies that considered PFV juices were reviewed. The impact of PFV juices on cancer risk was weakly positive, although a lack of human data and contradictory findings hampered conclusions. For CVD, there was convincing evidence from epidemiological and clinical studies that PFV juices reduced risk via a number of probable mechanisms. It was concluded that the view that PFV juices are nutritionally inferior to F&V, in relation to chronic disease risk reduction, is unjustified.

School food environments and practices affect dietary behaviors of US public school children

BACKGROUND

Changes to school food environments and practices that lead to improved dietary behavior are a powerful strategy to reverse the childhood obesity epidemic.

OBJECTIVES

To estimate the effects of school food environments and practices, characterized by access to competitive foods and beverages, school lunches, and nutrition promotion, on children's consumption of sugar-sweetened beverages, low-nutrient energy-dense foods, and fruits/vegetables at school.

DESIGN

Cross-sectional study using data from the third School Nutrition Dietary Assessment Study, a nationally representative sample of public school districts, schools, and children in school year 2004-2005. Data from school principals and foodservice directors, school menu analysis, and on-site observations were used to characterize school food environments and practices. Dietary intake was assessed using 24-hour recalls.

SUBJECTS/SETTING

The sample consists of 287 schools and 2,314 children in grades one through 12.

STATISTICAL ANALYSES PERFORMED

Ordinary least squares regression was used to identify the association between school food environments and practices (within elementary, middle, and high schools) and dietary outcomes, controlling for other school and child/family characteristics.

RESULTS

Sugar-sweetened beverages obtained at school contributed a daily mean of 29 kcal in middle school children and 46 kcal in high school children across all school children. Attending a school without stores or snack bars was estimated to reduce sugar-sweetened beverage consumption by 22 kcal per school day in middle school children (P<0.01) and by 28 kcal in high school children (P<0.01). The lack of a pouring rights contract in a school reduced sugar-sweetened beverage consumption by 16 kcal (P<0.05), and no à la carte offerings in a school reduced consumption by 52 kcal (P<0.001) in middle school children. The most effective practices for reducing energy from low-energy, energy-dense foods were characteristics of the school meal program; not offering french fries reduced low-nutrient, energy-dense foods consumption by 43 kcal in elementary school children (P<0.01) and sugar-sweetened beverage consumption by 41 kcal in high school children (P<0.001).

CONCLUSIONS

To improve children's diet and reduce obesity continued changes to school food environments and practices are essential. Removing sugar-sweetened beverages from school food stores and snack bars, improving à la carte choices, and reducing the frequency of offering french fries merit testing as strategies to reduce energy from low-nutrient, energy-dense foods at school.

Brief report: Adherence to fluid recommendations in children receiving treatment for retentive encopresis

OBJECTIVE

Limited data are available regarding whether children being treated for retentive encopresis are adherent to recommendations to increase their daily fluid intake. The purpose of this study was to examine fluid adherence in children who received treatment for retentive encopresis.

METHODS

A retrospective chart review was performed using diet diary data for 26 children (ages 3-12) who completed a group behavioral intervention for retentive encopresis.

RESULTS

Mean daily intake of clear fluid increased significantly during treatment and children relied primarily on water and juice to make this dietary change. However, adherence rates to clear fluid goals were <50%.

CONCLUSIONS

Children's increased clear fluid intake did not equate to high fluid adherence. Children's high juice consumption is concerning as it could place them at risk for other negative health consequences. Future research should examine whether enhanced fluid education and use of behavior change strategies yield higher fluid adherence.

Opportunities for the primary prevention of obesity during infancy

Many parents, grandparents, and clinicians have associated a baby’s ability to eat and gain weight as a sign of good health, and clinicians typically only call significant attention to infant growth if a baby is failing to thrive or showing severe excesses in growth. Recent evidence, however, has suggested that pediatric healthcare providers should pay closer attention to growth patterns during infancy. Both higher weight and upward crossing of major percentile lines on the weight-for-age growth chart during infancy have long term health consequences, and are associated with overweight and obesity later in life. Clinicians should utilize the numerous available opportunities to discuss healthy growth and growth charts during health maintenance visits in the first two years after birth. Further, providers should instruct parents on strategies to promote healthy behaviors that can have long lasting obesity preventive effects.

A pilot study describing infant formula preparation and feeding practices

Foodborne illnesses pose a problem to all individuals but are especially significant for infants. This observational study collected pilot data on formula preparation practices of 15 mothers of infants under the age of 7 months. A site survey tool was developed, based upon existing instruments. A trained observer traveled to the participants' homes to observe formula preparation and feeding. Some 73% of women did not wash their hands before preparing formula, 60% did not keep the prepared bottle cool during transport away from home, 53% checked the formula expiration date, 20% of infants slept with their bottle, 47% added cereal to formula, and 36% obtained information about formula preparation from a health professional. Hand washing is one of the most important home hygiene practices; however, hand washing practices by participants in our study prior to baby bottle preparation was poor.

Preventive oral health intervention for pediatricians

This policy is a compilation of current concepts and scientific evidence required to understand and implement practice-based preventive oral health programs designed to improve oral health outcomes for all children and especially children at significant risk of dental decay. In addition, it reviews cariology and caries risk assessment and defines, through available evidence, appropriate recommendations for preventive oral health intervention by primary care pediatric practitioners.

Benefits of Breakfast for Children and Adolescents: Update and Recommendations for Practitioners

A number of studies report health benefits for children and adolescents who consume breakfast. Breakfast skipping is fairly common in children and adolescents and increases as children age. Breakfast can enhance children's diets by positively contributing to daily nutrient intake, augmenting intake of key nutrients such as fiber and calcium, and provides an opportunity to help meet the recommendations of the Dietary Guidelines for Americans. Breakfast also is associated with more healthful food choices. Cross-sectional studies support that eating breakfast more often may help children and adolescents maintain a healthful weight. However, the results from longitudinal studies are inconclusive and suggest that more research is needed to clarify this relationship, including understanding the mediating effects of initial weight status, dieting behavior, and physical activity levels. Breakfast consumption may provide some benefit toward cognitive function and academic achievement, but more research is needed. Breakfast is one facet of a healthy lifestyle that may help contribute to the short- and long-term health and well-being of children and adolescents. Health practitioners can promote healthy breakfast consumption in children and adolescents by addressing barriers to eating breakfast and focusing on individuals who may be more likely to skip breakfast on a regular basis.

Selected complementary feeding practices and their association with maternal education

OBJECTIVE

As infants transition from a milk-based diet to one that includes most food groups, the timing of the transition, how infants are fed, and the quality of their diet can have important health implications. Our objective is to describe these factors for US infants.

METHODS

We analyzed data from the Infant Feeding Practices Study II. Sample sizes varied for relevant questions from approximately 1600 to approximately 2400. We analyzed the prevalence of 14 feeding practices and their association with the mothers' education and also examined participants' use of commercial baby foods.

RESULTS

Approximately 21% of the mothers introduced solid foods before 4 months; 7% introduced solids after 6 months. Twenty-nine percent of the mothers introduced > 3 new foods per week to infants aged 5 to 10 months. Approximately 20% of the mothers fed juice before 6 months, fed cow's milk before 12 months, and fed infants < 5 times per day after 5 months. Fourteen percent of the mothers chewed food for their infant. Approximately 15% of the mothers fed < 1 serving daily of either a fruit or vegetable to infants aged > or = 9 months, half added salt to their infant's food, and more than one third who added salt used noniodized salt. Approximately 20% fed reduced-fat cow's milk at 1 year. Almost half of the 10-month-old infants had eaten restaurant food in a restaurant in the previous week, 22% had eaten carry-out food, and 28% had eaten either type of restaurant food > or = 2 times. The prevalence of 8 of the 14 unhealthful infant feeding practices we examined was inversely associated with maternal education.

CONCLUSIONS

Nutrition and feeding guidance should be especially targeted to mothers with a high school education or less.

A Review of the Relationship Between 100% Fruit Juice Consumption and Weight in Children and Adolescents

Studies assessing a relationship between consumption of 100% fruit juice by children and adolescents and weight are contradictory. The purpose of this review was to assess the 9 cross-sectional and 12 longitudinal studies that have looked at this association. Of the 9 cross-sectional studies reviewed, only 3 reported any association. Those studies used small, local convenience samples of preschool children; furthermore, selection criteria were not well defined. One found that preschool children consuming ≥ 12 fluid oz/day of 100% fruit juice had a higher prevalence of overweight than those who consumed less than 12 oz/day (32% vs 9%). Later, a separate study showed that this relationship held only for apple juice. Another study demonstrated an association of overweight and energy from juice. These 3 studies were not nationally representative. Only 3 of the longitudinal studies showed an association between 100% fruit juice consumption and weight; 1 found an association only in adolescent girls, and 2 reported an association in children who were already overweight. None of the longitudinal studies was nationally representative, but 5 had sample sizes of at least 1000, 2 were ethnically diverse, and 3 had geographically separate sites, suggesting that the findings could be applicable to wider populations. Based on the currently available evidence, it can be concluded that there is no systematic association between consumption of 100% fruit juice and overweight in children or adolescents. Data do support consumption of 100% fruit juice in moderate amounts and suggest that consumption of 100% fruit juice may be an important strategy to help children meet the current recommendations for fruit.

Increasing caloric contribution from sugar-sweetened beverages and 100% fruit juices among US children and adolescents, 1988-2004

OBJECTIVE

We sought to document increases in caloric contributions from sugar-sweetened beverages and 100% fruit juice among US youth during 1988-2004.

PATIENTS AND METHODS

We analyzed 24-hour dietary recalls from children and adolescents (aged 2-19) in 2 nationally representative population surveys: National Health and Nutrition Examination Survey III (1988-1994, N = 9882) and National Health and Nutrition Examination Survey 1999-2004 (N = 10 962). We estimated trends in caloric contribution, type, and location of sugar-sweetened beverages and 100% fruit juice consumed.

RESULTS

Per-capita daily caloric contribution from sugar-sweetened beverages and 100% fruit juice increased from 242 kcal/day (1 kcal = 4.2 kJ) in 1988-1994 to 270 kcal/day in 1999-2004; sugar-sweetened beverage intake increased from 204 to 224 kcal/day and 100% fruit juice increased from 38 to 48 kcal/day. The largest increases occurred among children aged 6 to 11 years ( approximately 20% increase). There was no change in per-capita consumption among white adolescents but significant increases among black and Mexican American youths. On average, respondents aged 2 to 5, 6 to 11, and 12 to 19 years who had sugar-sweetened beverages on the surveyed day in 1999-2004 consumed 176, 229, and 356 kcal/day, respectively. Soda contributed approximately 67% of all sugar-sweetened beverage calories among the adolescents, whereas fruit drinks provided more than half of the sugar-sweetened beverage calories consumed by preschool-aged children. Fruit juice drinkers consumed, on average, 148 (ages 2-5), 136 (ages 6-11), and 184 (ages 12-19) kcal/day. On a typical weekday, 55% to 70% of all sugar-sweetened beverage calories were consumed in the home environment, and 7% to 15% occurred in schools.

CONCLUSIONS

Children and adolescents today derive 10% to 15% of total calories from sugar-sweetened beverages and 100% fruit juice. Our analysis indicates increasing consumption in all ages. Schools are a limited source for sugar-sweetened beverages, suggesting that initiatives to restrict sugar-sweetened beverage sales in schools may have an only marginal impact on overall consumption. Pediatricians' awareness of these trends is critical for helping children and parents target suboptimal dietary patterns that may contribute to excess calories and obesity.

The use of multiple logistic regression to identify risk factors associated with anemia and iron deficiency in a convenience sample of 12-36-mo-old children from low-income families

BACKGROUND

The prevalence of iron deficiency (ID) anemia among preschool-age children remains relatively high in some areas across the United States. Determination of risk factors associated with ID is needed to allow children with identifiable risk factors to receive appropriate education, testing, and follow-up.

OBJECTIVE

We aimed to evaluate risk factors associated with anemia and ID in a sample of children participating in or applying for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

DESIGN

The study was a cross-sectional study of a convenience sample of 12-36-mo-old children recruited from WIC clinics in 2 California counties (n = 498).

RESULTS

Current WIC participation by the child and a greater rate of weight gain were negatively associated, and current maternal pregnancy was positively associated with anemia (hemoglobin < 110 g/L at 12-<24 mo or < 111 g/L at 24-36 mo) after control for age, sex, and ethnicity. Maternal WIC participation during pregnancy, child age, and the intake of > or =125 mL orange or tomato juice/d were negatively associated, and being male and living in an urban location were positively associated with ID (> or =2 of the following abnormal values: ferritin < or = 8.7 microg/L, transferrin receptors > or = 8.4 microg/mL, and transferrin saturation < or = 13.2%).

CONCLUSIONS

Current WIC participation by the child and maternal WIC participation during pregnancy were negatively associated with anemia and ID, respectively. It is anticipated that the risk factors identified in this study will be included in the development of an educational intervention focused on reducing the risk factors for ID and ID anemia in young children.

Nutrition Review: Lifestyle Approaches to Promoting Healthy Eating for Children

Healthy eating habits are vital to establish during childhood and sustain thereafter. Nourishing, well-balanced diets are essential for proper growth, immunity, physical and mental development, health and well-being, and reduced risk of chronic diseases later in life. Health care professionals, parents, and teachers should be aware of common nutrition-related concerns in children and teens, such as dental caries, allergies, anemia, growth retardation, eating disorders, and obesity, and watch for indicators that a child may be at risk for these. Foods that comprise a healthy diet for children include vegetables, fruits, whole grains, legumes, low-fat dairy products, and lean sources of protein. Foods and beverages with low nutrient density and high energy density should be consumed in moderation only, within a child's discretionary calorie allowance. Although children may need to eat more frequently than adults, they should be taught healthy snacking practices. Role modeling and nutrition education from adults in children's lives are critical in promoting lifelong healthy eating. Resources to facilitate these include Web sites from the American Academy of Pediatrics, American Dietetics Association, MyPyramid.gov/kids, and the US Dietary Guidelines.

Hydration in children

Water supply is a basic public problem. In modern science, three periods with different approaches to define recommended water intake in adults can be distinguished. Pediatricians agree that hydration in children may be optimal only in breastfed infants. More data are required on the health effects of different hydration states and varying water intakes in particular age and gender groups to define optimal ranges of water intake. The fetus grows in an exceptionally well-hydrated environment. Water metabolism shows several peculiarities in preterm and term infants. Infant diarrhea remains a major topic of basic and clinical research. Water intoxication in infants, toddlers, and children is rare and can only be found in exceptional circumstances. Hydration status characterized by hyponatremia may play a role in the pathogenesis of febrile convulsions in toddlers. There is increasing indirect evidence that spontaneous drinking behavior of a population may be fixed and anchored in the age range of toddlers. Sex differences in hydration status are common, but not obligatory. What causes theses differences? What is behind the various circadian rhythms of urine osmolality in children? At what age and in what quantities can alcohol and caffeine consumption be tolerated? How can individual susceptibility be defined? Reflecting on the modern epidemic of obesity in children and adolescents, a public consensus concerning use and misuse of sweetened drinks seems mandatory. Dietary reference intakes of water refer to 24-hour intake. In nutritional counselling, food and meal-based dietary advice is primarily given. Young parents are confronted with a flood of advice of varying quality. Recommendations on fluid consumption should be collated and revised.

Recommendations for treatment of child and adolescent overweight and obesity

In this article, we review evidence about the treatment of obesity that may have applications in primary care, community, and tertiary care settings. We examine current information about eating behaviors, physical activity behaviors, and sedentary behaviors that may affect weight in children and adolescents. We also review studies of multidisciplinary behavior-based obesity treatment programs and information about more aggressive forms of treatment. The writing group has drawn from the available evidence to propose a comprehensive 4-step or staged-care approach for weight management that includes the following stages: (1) Prevention Plus; (2) structured weight management; (3) comprehensive multidisciplinary intervention; and (4) tertiary care intervention. We suggest that providers encourage healthy behaviors while using techniques to motivate patients and families, and interventions should be tailored to the individual child and family. Although more intense treatment stages will generally occur outside the typical office setting, offices can implement less intense intervention strategies. We not ony address specific patient behavior goals but also encourage practices to modify office systems to streamline office-based care and to prepare to coordinate with professionals and programs outside the office for more intensive interventions.

Recommendations for prevention of childhood obesity

The majority of US youth are of healthy weight, but the majority of US adults are overweight or obese. Therefore, a major health challenge for most American children and adolescents is obesity prevention-today, and as they age into adulthood. In this report, we review the most recent evidence regarding many behavioral and practice interventions related to childhood obesity, and we present recommendations to health care providers. Because of the importance, we also suggest approaches that clinicians can use to encourage obesity prevention among children, including specific counseling strategies and practice-based, systems-level interventions. In addition, we suggest how clinicians may interact with and promote local and state policy initiatives designed to prevent obesity in their communities.

Variability and uncertainty assessment of patulin exposure for preschool children in Flanders

The objective of the present study was to evaluate the patulin exposure of children consuming organic, handcrafted or conventional apple juice through a probabilistic approach and to evaluate the effectiveness of several risk management options aiming to reduce the risk for children due to patulin exposure. However, a large part of the data on patulin contamination of apple juice fell under the limit of detection (LOD). Different methods were tested to deal with these so-called left censored data and a uniform distribution with uncertain bounds was selected to handle this censorship. Variability and uncertainty assessment of patulin exposure showed that 0.9% [90% confidence interval (CI): 0.3-1.8%] of the children consuming only organic apple juice exceed the tolerable daily intake (TDI). For consumers of conventional and handcrafted apple juice this was respectively 0.1% [90% CI: 0-0.3%] and 0% [90% CI: 0-0.2%]. Reduction of the patulin contamination in apple juice to concentrations below 25 microg/kg reduced the percentage of the children exceeding the TDI to 0% [90%CI: 0-0.2%] for organic apple juice. Reduction of the apple juice consumption was less effective than a reduction of the patulin concentration in apple juice and is only useful when the patulin concentration of apple juice is below 25 microg/kg.

Fructose metabolism in the cerebellum

Under normal physiological conditions, the brain utilizes only a small number of carbon sources for energy. Recently, there is growing molecular and biochemical evidence that other carbon sources, including fructose, may play a role in neuro-energetics. Fructose is the number one commercial sweetener in Western civilization with large amounts of fructose being toxic, yet fructose metabolism remains relatively poorly characterized. Fructose is purportedly metabolized via either of two pathways, the fructose-1-phosphate pathway and/or the fructose-6-phosphate pathway. Many early metabolic studies could not clearly discriminate which of these two pathways predominates, nor could they distinguish which cell types in various tissues are capable of fructose metabolism. In addition, the lack of good physiological models, the diet-induced changes in gene expression in many tissues, the involvement of multiple genes in multiple pathways involved in fructose metabolism, and the lack of characterization of some genes involved in fructose metabolism have complicated our understanding of the physiological role of fructose in neuro-energetics. A recent neuro-metabolism study of the cerebellum demonstrated fructose metabolism and co-expression of the genes specific for the fructose 1-phosphate pathway, GLUT5 (glut5) and ketohexokinase (khk), in Purkinje cells suggesting this as an active pathway in specific neurons? Meanwhile, concern over the rapid increase in dietary fructose, particularly among children, has increased awareness about how fructose is metabolized in vivo and what effects a high fructose diet might have. In this regard, establishment of cellular and molecular studies and physiological characterization of the important and/or deleterious roles fructose plays in the brain is critical. This review will discuss the status of fructose metabolism in the brain with special reference to the cerebellum and the physiological roles of the different pathways.

Counseling parents on feeding their children

PURPOSE OF REVIEW

The high-nutrient needs of children for normal growth and development are matched by ready access to low-nutrient high-energy foods. Parents are often confused by new and at times conflicting information. This review discusses three recently published papers that offer specific and important dietary information for school-aged children.

RECENT FINDINGS

Lactose intolerance is common in some populations and there are misconceptions about dairy intake. Most lactose-intolerant children can consume some dairy products without symptoms. Fruit-juice intake can predict increased weight gain in children, especially those who are already overweight or at risk for being overweight. Hypertension is a serious disease with onset likely in childhood. This paper discusses the importance of dietary sodium as a contributor to the development of hypertension, and the sodium content of children's diets.

SUMMARY

Advice to parents on feeding children should be based on the food pyramid and include information on exercise. Recent publications suggest that children consume dairy products, even if lactose intolerant, restrict juice intake, remove sweetened beverages from their diets and reduce sodium consumption.

Are dietary intakes and eating behaviors related to childhood obesity? A comprehensive review of the evidence

The purpose of this article is to comprehensively review studies that have examined the relation between diet and childhood obesity. The review specifically considers the roles of total energy intake and energy density; dietary composition; individual foods, food groups, and dietary patterns; beverage consumption; and eating behaviors. The paper also discusses methodological considerations and future research directions and concludes by summarizing the evidence presented and highlighting the ethical issues surrounding providing dietary advice.

Meeting adequate intake for dietary calcium without dairy foods in adolescents aged 9 to 18 years (National Health and Nutrition Examination Survey 2001-2002)

BACKGROUND

In the United States, >50% of dietary calcium is provided by milk and milk products. Calcium intakes in the United States are inadequate for many children, and a large proportion do not drink milk or consume dairy products. However, no studies have addressed whether dairy-free diets can provide adequate calcium while meeting other nutrient recommendations.

OBJECTIVE

To determine the highest calcium intake for adolescents obtained from dairy-free diets, and to examine the relationship between intakes of calcium-fortified foods, using citrus juice as an example, and maximal calcium intakes.

DESIGN

In the National Health and Nutrition Examination Survey 2001 to 2002, 65 females and 62 males, aged 9 to 18 years, reported no intake of dairy. We used linear programming to generate diets with maximal calcium intake, while meeting Dietary Reference Intakes for a set of nutrients, limiting energy and fat intakes, and not selecting food quantities exceeding amounts usually eaten in the population.

RESULTS

With food use and energy and fat constraints, diets formulated by linear programming provided 1,150 and 1,411 mg/day of calcium for girls and boys, respectively. With the Dietary Reference Intakes constraints, these decreased to 869 and 1,160 mg/day. When we introduced 1.5 servings of fortified juice to the diets, the highest calcium intake increased to 1,302 mg/day for girls and to 1,640 mg/day for boys.

CONCLUSIONS

Adequate intake for calcium cannot be met with dairy-free diets while meeting other nutrient recommendations. To meet the adequate intake for calcium without large changes in dietary patterns, calcium-fortified foods are needed. In addition, greater physical activity and responsible sunlight exposure should be encouraged to promote vitamin D adequacy.

Fruit juice intake predicts increased adiposity gain in children from low-income families: weight status-by-environment interaction

OBJECTIVE

Our goal was to test the hypothesis that increased fruit juice intake and parental restriction of children's eating are associated with increased adiposity gain and whether exposure to nutritional counseling predicted reduced adiposity gain among children.

PATIENTS AND METHODS

A sample of parents or guardians of children aged 1 to 4 years who attended 1 of 49 Special Supplemental Nutrition Program for Women, Infants, and Children agencies in New York State were surveyed in 1999 or 2000 (N = 2801). The survey addressed children's dietary intake, parental feeding practices, and parental exposure to nutritional counseling messages to increase fruit, vegetable, and low-fat milk intakes. Each child's height and weight were measured approximately every 6 months for up to 48 months. A prospective cohort design was used in which survey variables were the predictors and the outcome was change in children's adiposity, defined as change in age- and gender-standardized BMI per month (ie, BMI z-score slope).

RESULTS

Controlling for gender and ethnicity, the relationship between juice intake and adiposity gain depended on children's initial overweight status. Among children who were initially either at risk for overweight or overweight, increased fruit juice intake was associated with excess adiposity gain, whereas parental offerings of whole fruits were associated with reduced adiposity gain. Each additional daily serving of fruit juice was associated with an excess adiposity gain of 0.009 SD per month. Feeding restriction was greater among parents whose children were initially at risk for overweight or overweight compared with those at a healthy weight. Parental exposure to nutritional messages was not associated with reduced child adiposity gain.

CONCLUSION

This study supports the Institute of Medicine recommendations to reduce fruit juice intake as a strategy for overweight prevention in high-risk children.

MyPyramid food intake pattern modeling for the Dietary Guidelines Advisory Committee

Modeling analyses using the MyPyramid intake patterns were conducted in collaboration with the 2005 Dietary Guidelines Advisory Committee in response to their research questions and to determine likely effects of possible recommendations on overall dietary adequacy. Scenarios modeled included the feasibility of using the food patterns for lacto-ovo-vegetarian diets, of varying fat levels within the patterns, and of increasing dietary flexibility through food group substitutions. Food pattern modeling was a useful tool to identify possible impacts on diet quality of potential Dietary Guidelines recommendations. Modeling analyses can help researchers explore the overall effect of specific dietary recommendations on intake patterns.

Drowning in a sea of advice: pediatricians and American Academy of Pediatrics policy statements

OBJECTIVE

The proliferation of policy statements from the American Academy of Pediatrics presents pediatricians with an increasing amount of health advice to deliver, yet no quantitative estimates of pediatric health advice expectations exist in the literature. The objective of this study was to quantify and characterize verbal health advice that pediatricians are expected to deliver to patients/guardians.

METHODS

The authors read and coded the 344 American Academy of Pediatrics policy statements that are contained in the American Academy of Pediatrics' Pediatric Clinical Practice Guidelines and Policies, Third Edition, and identified 57 policies that contained health advice directives that are broadly relevant to pediatric practice. We extracted the individual advice text to a database in which we also coded its date of issue, its theme, and whether (1) it was duplicated in another policy, (2) a screening question was required to identify a target population for the advice, (3) handouts or other aids to delivering the advice were referenced in the policy itself, or (4) the text of the statement referred to evidence of the effectiveness of office-based delivery of the advice.

RESULTS

These 57 policies were found to contain 192 discrete health advice directives that pediatricians are expected to deliver to patients/guardians. Seven (4%) of these directives originated before 1993, and 185 (96%) were created from 1993 to 2002. After removal of the 30 (16%) duplicates, safety advice composed 67%, media use composed 12%, substance abuse composed 5%, environmental health hazards composed 4%, development/emotional health composed 4%, sexuality and pregnancy composed 3%, nutrition composed 2%, and miscellaneous composed 3%. In 41% of the directives, a screening question was required to identify the target population for the advice. Aids to delivering advice were referenced in 20% of the policies. In no policy statements did the text refer to evidence that office-based counseling was an effective method to achieve the desired health or behavioral outcome.

CONCLUSIONS

We examined the American Academy of Pediatrics policy statements and found 162 different verbal health advice directives on which pediatricians should counsel parents and patients throughout childhood. The expectation that delivery of all of this advice can be achieved is unrealistic. Moreover, none of the reviewed statements were found to include an evidence-based discussion of the efficacy of the suggested advice. In light of these findings, we suggest that committees should consider both the feasibility and the evidence of efficacy of office-based health advice when generating future policy statements.

Beverage intake among preschool children and its effect on weight status

OBJECTIVE

The obesity epidemic in the United States continues to increase. Because obesity tends to track over time, the increase in overweight among young children is of significant concern. A number of eating patterns have been associated with overweight among preschool-aged children. Recently, 100% fruit juice and sweetened fruit drinks have received considerable attention as potential sources of high-energy beverages that could be related to the prevalence of obesity among young children. Our aim was to evaluate the beverage intake among preschool children who participated in the National Health and Nutrition Examination Survey 1999-2002 and investigate associations between types and amounts of beverages consumed and weight status in preschool-aged children.

METHODS

We performed a secondary analysis of the data from the National Health and Nutrition Examination Survey 1999-2002, which is a continuous, cross-sectional survey of a nationally representative sample of the noninstitutionalized population of the United States. It included the collection of parent reported demographic descriptors, a 24-hour dietary recall, a measure of physical activity, and a standardized physical examination. The 24-hour dietary recall was obtained in person by a trained interviewer and reflected the foods and beverages that were consumed by the participant the previous day. The National Health and Nutrition Examination Survey food groups were classified on the basis of the US Department of Agriculture's Food and Nutrient Database for Dietary Studies. We reviewed the main food descriptors used and classified all beverages listed. One hundred percent fruit juice was classified as only beverages that contained 100% fruit juice, without sweetener. Fruit drinks included any sweetened fruit juice, fruit-flavored drink (natural or artificial), or drink that contained fruit juice in part. Milk included any type of cow milk and then was subcategorized by percentage of milk fat. Any sweetened soft drink, caffeinated or uncaffeinated, was categorized as soda. Diet drinks included any fruit drink, tea, or soda that was sweetened by low-calorie sweetener. Several beverages were removed from the analysis because of low frequency of consumption among the sample. Water was not included in the analysis because it is not part of the US Department of Agriculture's Food and Nutrient Database categories. For the purposes of this analysis, the beverages were converted and reported as ounces, rather than grams, as reported by the National Health and Nutrition Examination Survey, to make it more clinically relevant. The child's BMI percentile for age and gender were calculated on the basis of Centers for Disease Control and Prevention criteria and used to identify children's weight status as underweight (< 5%), normal weight (5% to < 85%), at risk for overweight (85% to < 95%), or overweight (> or = 95%). Because of the small number of children in the underweight category, they were included in the normal-weight category for this analysis. Data were analyzed using SUDAAN 9.0.1 statistical software programs. SUDAAN allows for improved accuracy and validity of results by calculating test statistics for the stratified, multistage probability design of the National Health and Nutrition Examination Survey. Sample weights were applied to all analyses to account for unequal probability of selection from oversampling low-income children and black and Mexican American children. Descriptive and chi2 analyses and analysis of covariance, adjusting for age, gender, ethnicity, household income, energy intake, and physical activity, were conducted.

RESULTS

All children who were aged 2 to 5 years were identified (N = 1572). Those with missing data were removed from additional analysis, resulting in a final sample of 1160 preschool children. Of the 1160 children analyzed, 579 (49.9%) were male. White children represented 35%, black children represented 28.3%, and Hispanic children represented 36.7% of the sample. Twenty-four percent of the children were overweight or at risk for overweight (BMI > or = 85%), and 10.7% were overweight (BMI > or = 95%). There were no statistically significant differences in BMI between boys and girls or among the ethnicities. Overweight children tended to be older (mean age: 3.83 years) compared with the normal-weight children (mean age: 3.48 years). Eighty-three percent of children drank milk, 48% drank 100% fruit juice, 44% drank fruit drink, and 39% drank soda. Whole milk was consumed by 46.5% of the children, and 3.1% and 5.5% of the children consumed skim milk and 1% milk, respectively. Preschool children consumed a mean total beverage volume of 26.93 oz/day, which included 12.32 oz of milk, 4.70 oz of 100% fruit juice, 4.98 oz of fruit drinks, and 3.25 oz of soda. Weight status of the child had no association with the amount of total beverages, milk, 100% fruit juice, fruit drink, or soda consumed. There was no clinically significant association between the types of milk (percentage of fat) consumed and weight status. In analysis of covariance, daily total energy intake increased with increased consumption of milk, 100% fruit juice, fruit drinks, and soda. However, there was not a statistically significant increase in BMI on the basis of quantity of milk, 100% fruit juice, fruit drink, or soda consumed.

CONCLUSIONS

On average, preschool children drank less milk than the 2005 Dietary Guidelines for Americans recommendation of 16 oz/day. Only 8.6% drank low-fat or skim milk, as recommended for children who are older than 2 years. On average, preschool children drank < 6 oz/day 100% fruit juice. Increased beverage consumption was associated with an increase in the total energy intake of the children but not with their BMI. Prospectively studying preschool children beyond 2 to 5 years of age, through their adiposity rebound (approximately 5.5-6 years) to determine whether there is a trajectory increase in their BMI, may help to clarify the role of beverage consumption in total energy intake and weight status.

Maternal and child characteristics associated with infant and toddler feeding practices

OBJECTIVE

To describe maternal/child characteristics associated with important practices of feeding US infants and toddlers aged 4 to 24 months.

DESIGN

Cross-sectional analysis of data collected in the 2002 Feeding Infants and Toddlers Study. Maternal/child characteristics associated with compliance to American Academy of Pediatrics feeding guidelines, and maternal/child characteristics associated with specific feeding patterns were assessed.

SUBJECTS

A national random sample of mothers (n=2,515) whose infants and toddlers aged 4 to 24 months made up the Feeding Infants and Toddlers Study cohort.

STATISTICAL ANALYSIS

Student t tests were used to compare the means and standard errors and were considered significant if P<.05. To predict if the mother/child met a particular recommendation, logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals.

RESULTS

Having a college education was the maternal characteristic associated with the largest number of positive child feeding behaviors. Mothers with a college education were significantly more likely than mothers without a college education to initiate breastfeeding and breastfeed the child to age 6 and 12 months (OR 2.8, 3.2, and 3.9, respectively). College-educated mothers were significantly more likely to comply with the American Academy of Pediatrics juice and complementary feeding recommendations (OR 1.4 and 2.0). In addition, infants and toddlers whose mother had a college education were more likely to consume fruit and less likely to consume sweetened beverages and desserts or candy. Ever breastfeeding the sample child, living in the western region of the United States, and being married and older were also associated with multiple positive practices. The child being in day care was associated with decreased duration of breastfeeding at age 6 and 12 months as well as with consumption of salty snacks.

CONCLUSIONS

Initiatives to improve infant and toddler feeding practices should focus on assisting mothers who have less than a college education, who are unmarried, whose child is in day care, or who are enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children.

Feeding Infants and Toddlers Study: meal and snack intakes of Hispanic and non-Hispanic infants and toddlers

OBJECTIVE

To describe meal and snack patterns of Hispanic and non-Hispanic infants and toddlers.

DESIGN

A cross-sectional telephone survey in which mothers or other primary caregivers reported their infants' and toddlers' food and beverage intake for a 24-hour period.

SUBJECTS/SETTING

Subjects were a subset of the national random sample of children aged 4-24 months who participated in the 2002 Feeding Infants and Toddlers Study. The Feeding Infants and Toddlers Study includes a stratified random sample of 3,022 infants and toddlers aged 4-24 months. Three hundred seventy-one Hispanic and 2,637 non-Hispanic children who had 24-hour dietary recalls are included in the subset.

ANALYSES

Means+/-standard errors of daily intakes of energy, nutrients, and nutrient densities were calculated, as were percentages of children consuming foods at each eating occasion.

RESULTS

Hispanic and non-Hispanic infants and toddlers, on average, were fed seven times per day. Overall, the percentages of children who ate snacks increased with age, and more than 80% of toddlers aged 12-24 months consumed afternoon snacks, with more than 90% of Hispanic children consuming an afternoon snack. In each age group, there were significant differences between ethnic groups in nutrient intakes by eating occasion. No significant difference was seen for energy across all meal occasions. At age 6-11 months, Hispanic children had a significantly lower intake of carbohydrate at dinner and lower intake of saturated fat at afternoon snacks compared with non-Hispanic children (P<.05). The main difference between Hispanic children's and non-Hispanic children's intakes by eating occasion is at age 12-24 months. Hispanics aged 12-24 months had significantly (P<.05) lower percentages of energy from fat and saturated fat and a significantly (P<.05) higher percentage of carbohydrate at lunch compared with non-Hispanic children. For dinner, Hispanic toddlers had significantly (P<.05) lower intakes of total fat and saturated fat compared with non-Hispanic toddlers at age 12-24 months. Overall fiber intake contributed 2 g/meal for both ethnic groups. Snacks contributed, on average, less than 1 g fiber, except Hispanic toddlers had significantly higher fiber intake at afternoon snacks (1.5 g) than non-Hispanic toddlers. Foods frequently consumed at meals and snacks were lacking in whole grains, vegetables, and fruits. Most nutrients were not significantly different between Hispanics and non-Hispanics for meals and snacks.

CONCLUSIONS

Considering the sizeable contribution that snacks make toward overall energy, parents and caregivers should plan toddlers' snacks to complement meals by including additional fruits, vegetables, and whole grains that are culturally appropriate rather than fruit drinks, cookies, and crackers. This will increase fiber intake and limit fat and sugar intakes. To develop healthful eating patterns, introduce toddlers to foods eight to 10 times to increase food acceptance and the likelihood of establishing healthful eating patterns. Dietetics professionals need to consider cultural differences when developing meal and snack patterns for Hispanic and non-Hispanic infants and toddlers.

Breastfeeding, introduction of complementary foods, and adiposity at 5 y of age

BACKGROUND

Although dual-energy X-ray absorptiometry (DXA) is considered the most accurate measure of adiposity in children, it has rarely been used to examine the relation between infant feeding and adiposity during childhood.

OBJECTIVE

The objective was to ascertain whether adiposity at age 5 y was related to breastfeeding, to the timing of the introduction of complementary foods during infancy, or to both.

DESIGN

Body composition was measured in 313 children at age 5 y by using DXA. Data on breastfeeding, formula feeding, and the timing of the introduction of complementary foods were obtained from the mothers when the children were 3 y old. Regression analysis was used to examine the relation between infant feeding and fat mass after adjustment for lean body mass, sex, birth weight, maternal obesity, race, and other sociodemographic variables.

RESULTS

Fifty-three percent of the children were boys, 80% were white, and 20% were black. There was no significant difference in adjusted fat mass between those ever breastfed and those never breastfed (x +/- SE: 4.48 +/- 0.09 and 4.76 +/- 0.17 kg, respectively; P = 0.17). Children who were breastfed for a longer duration and those who were breastfed without concurrent formula feeding did not have significantly lower fat mass than did those children who were never breastfed. Children did not differ significantly in fat mass if they were introduced to complementary foods before or after 4 mo of age (4.49 +/- 0.12 and 4.63 +/- 0.12 kg, respectively; P = 0.42).

CONCLUSION

Neither breastfeeding nor the timing of the introduction of complementary foods was associated with adiposity at age 5 y.

Optimizing bone health and calcium intakes of infants, children, and adolescents

Most older children and adolescents in the United States currently do not achieve the recommended intake of calcium. Maintaining adequate calcium intake during childhood and adolescence is necessary for the development of peak bone mass, which may be important in reducing the risk of fractures and osteoporosis later in life. Optimal calcium intake is especially relevant during adolescence, when most bone mineral accretion occurs. Because of the influence of the family's diet on the diet of children and adolescents, adequate calcium intake by all members of the family is important. Assessment of calcium intake can be performed in the physician's office. A well-rounded diet including low-fat dairy products, fruits, and vegetables and appropriate physical activity are important for achieving good bone health. Establishing these practices in childhood is important so that they will be followed throughout the life span.

Dietary recommendations for children and adolescents: a guide for practitioners

Since the American Heart Association last presented nutrition guidelines for children, significant changes have occurred in the prevalence of cardiovascular risk factors and nutrition behaviors in children. Overweight has increased, whereas saturated fat and cholesterol intake have decreased, at least as percentage of total caloric intake. Better understanding of children's cardiovascular risk status and current diet is available from national survey data. New research on the efficacy of diet intervention in children has been published. Also, increasing attention has been paid to the importance of nutrition early in life, including the fetal milieu. This scientific statement summarizes current available information on cardiovascular nutrition in children and makes recommendations for both primordial and primary prevention of cardiovascular disease beginning at a young age.

The roles of meal, snack, and daily total food and beverage exposures on caries experience in young children

OBJECTIVES

This study describes associations among caries experience and meal, snack and daily total exposures to beverages and foods in children.

METHODS

Subjects (n = 634) were members of the Iowa Fluoride Study. Beverage and food exposures were abstracted from 3-day diaries at 1, 2, 3, 4 and 5 years and calculated for 1-5 years. Eating events were defined as 30-minute intervals and categorized as meals or snacks based on time of consumption and nature of the foods. Beverage and food exposures were categorized by carbohydrate content. Dental examinations were conducted at 4.5-6.8 years; caries experience was dichotomized (any vs. none). Logistic regression models were developed to determine if caries experience differed for the fourth vs. first quartile of exposure after adjustment for age at dental exam and fluoride intake.

RESULTS

Higher snack (1, 2, 3, 4, 1-5 years) and daily total (2, 3, 4, 1-5 years) eating events increased caries risk (P < 0.05). Higher exposures to 100% juice at snacks (2 years) and soda pop at meals (2, 1-5 years), snacks (2, 3, 4, 1-5 years) and daily total (2, 3, 4, 1-5 years) increased caries risk (P < 0.05). Higher exposures to food sugars (3, 1-5 years) and starches (4, 5, 1-5 years) at meals decreased caries risk, while higher exposures to sugars (4, 1-5 years) at snacks increased caries risk (P < 0.05).

CONCLUSIONS

Dietary methods used to investigate diet-caries relationships can influence the outcome. The cariogenicity of food, but not beverages, is associated with the timing of exposure.

Dietary Recommendations for Children and Adolescents

Since the American Heart Association last presented nutrition guidelines for children, significant changes have occurred in the prevalence of cardiovascular risk factors and nutrition behaviors in children. Overweight has increased, whereas saturated fat and cholesterol intake have decreased, at least as percentage of total caloric intake. Better understanding of children’s cardiovascular risk status and current diet is available from national survey data. New research on the efficacy of diet intervention in children has been published. Also, increasing attention has been paid to the importance of nutrition early in life, including the fetal milieu. This scientific statement summarizes current available information on cardiovascular nutrition in children and makes recommendations for both primordial and primary prevention of cardiovascular disease beginning at a young age.

Safety assessment and risk–benefit analysis of the use of azodicarbonamide in baby food jar closure technology: Putting trace levels of semicarbazide exposure into perspective – A review

The discovery of trace levels of semicarbazide (SEM) in bottled foods (especially baby foods) led to a consideration of the safety of this hydrazine compound by regulatory agencies worldwide. Azodicarbonamide, which is used in the jar-sealing technology known as Press On-Twist Off (or Push-Twist/PT) closures for the formation of a hermetic, plastisol seal, partially degrades with the heat of processing to form trace amounts of SEM. This review has evaluated the potential toxicological risks of resulting exposure to SEM and also the benefit of the PT technology (with azodicarbonamide) in the context of possible microbial contamination. It also considers the potential impact on infant nutrition if parents come to the conclusion that commercial baby foods are unsafe. SEM shows limited genotoxicity in vitro that is largely prevented by the presence of mammalian metabolic enzymes. Negative results were found in vivo in DNA alkaline elution, unscheduled DNA synthesis and micronucleus assays. This pattern is in contrast to the genotoxic hydrazines that also have been shown to cause tumours. Carcinogenicity studies of SEM are of limited quality, show a questionable weak effect in mice at high doses, which are not relevant to human exposure at trace levels, and show no effect in the rat. The IARC has assigned SEM as Group 3, 'Not classifiable as to its carcinogenicity to humans'. Based on estimates of exposure to infants consuming baby foods (with the assumption of SEM levels at the 95th percentile of 20 ng g(-1) in all of the consumed 'ready-to-eat' foods) compared with a no observed adverse effect level (NOAEL) in developmental toxicity studies, the margin of safety is more than 21 000. Since the risk of an adverse effect is negligible, it is clear that any theoretical risk is outweighed by the benefits of continuing use of the PT closure (with azodicarbonamide blowing agent) to ensure both the microbial integrity and availability of commercial baby foods as a valuable source of infant nutrition.

Position of the American Dietetic Association: benchmarks for nutrition programs in child care settings

It is the position of the American Dietetic Association that all child care programs should achieve recommended benchmarks for meeting children's nutrition and nutrition education needs in a safe, sanitary, and supportive environment that promotes healthy growth and development. Use of child care is the norm for America's families. It is essential, therefore, that nutrition professionals work in partnership with child care providers and with children's families to ensure that meals and snacks consumed in child care settings meet children's nutrition needs and provide them with excellent models of healthy dietary patterns. This position provides guidance and information about resources for nutrition professionals, health care practitioners, child care providers, and parents regarding meal plans, food preparation and food service, physical and social environment, and nutrition consultation and training for child care.