Gastroenteritis, diarrhoea and breast feeding

Breastfeeding With Infectious Diseases

Aims: Human breast milk remains an important source of protection against infection, inflammation, allergy and long-term metabolic disorders for the breastfed offspring. During cases of ongoing infection, the dilemma faced by both medical health professionals and mothers is the need to balance the risk of continuing versus temporarily or permanently ceasing to breastfeed. The aim of our article is to review existing literature regarding breastfeeding during acute infectious and non-infectious illnesses and to provide feasible evidence-based suggestions which can be implemented by medical practitioners during counselling of breastfeeding mothers.

Method: A literature search was conducted on PubMed (US National Library of Medicine) using various combinations of keywords related to breastfeeding and the various infections. The citations from all selected articles were reviewed for additional studies.

Results: Most ongoing infections are not contraindications for breastfeeding, with the exceptions of Human Immunodeficiency viruses (HIV), Human T-cell lymphotropic virus (HTLV) types 1 and 2. Even with HIV, there is increasing evidence to reassure that with adequate antiretroviral therapy, breastfeeding is likely to be safe. Of particular concern during the COVID-19 pandemic too, current evidence indicates that mothers with COVID-19 infection can safely breastfeed, and therefore initiation and continuation of breastfeeding should continue to protect the health of the babies and mothers.

Conclusion: During this pandemic especially, there is a strong and urgent need to support mothers with acute infections who wish to breastfeed. With better awareness, physicians can play an important role in securing positive experiences for breastfeeding mothers and optimizing infant outcomes.

Norovirus-specific immunoglobulin A in breast milk for protection against norovirus-associated diarrhea among infants

BACKGROUND

Norovirus (NV) causes acute gastroenteritis in infants. Humoral and fecal immunoglobulin A (IgA) responses have been correlated with protection against NV; however, the role of breast milk IgA against NV infection and associated diarrhea is still unknown. This study aimed to evaluate the protective role of NV-specific IgA (NV-IgA) in breast milk.

METHODS

Ninety-five breast milk samples collected from mothers enrolled in a 2016-2017 Peruvian birth cohort study were tested for total IgA and NV-IgA by ELISA using GII·4 variants and non-GII·4 genotype virus-like particles (VLPs). Breast milk samples were grouped according to the NV infection and diarrheal status of infants: NV positive with diarrhea (NV+D+, n=18); NV positive without diarrhea (NV+D-, n=37); and NV negative without diarrhea (NV-D-, n=40). The percent positivity and titer of NV-IgA were compared among groups. The cross-reactivity was estimated based on the correlation of ratio between NV-IgA against GII·4 variants and non-GII·4 genotype VLPs.

FINDINGS

NV-IgA had high positivity rates against different VLPs, especially against GII (89-100%). The NV+D- group had higher percent positivity (89% vs. 61%, p=0·03) and median titer (1:100 vs 1:50, p=0·03) of NV-IgA than the NV+D+ group against GI·1 VLPs. A relatively high correlation between different GII·4 variants (0·87) and low correlation between genogroups (0·23-0·37) were observed.

INTERPRETATION

Mothers with high positivity rates and titers of NV-IgA in breast milk had NV infected infants with reduced diarrheal symptoms. Antigenic relatedness to the genetic diversity of human norovirus was suggested.Funding National Institute of Allergy and Infectious Diseases, National Institute of Health: 1R01AI108695-01A1 and the Japan Society for the Promotion of Science (Fostering Joint International Research B):19KK0241.

Metabolism-related microRNAs in maternal breast milk are influenced by premature delivery

BackgroundMaternal breast milk (MBM) is enriched in microRNAs, factors that regulate protein translation throughout the human body. MBM from mothers of term and preterm infants differs in nutrient, hormone, and bioactive-factor composition, but the microRNA differences between these groups have not been compared. We hypothesized that gestational age at delivery influences microRNA in MBM, particularly microRNAs involved in immunologic and metabolic regulation.MethodsMBM from mothers of premature infants (pMBM) obtained 3-4 weeks post delivery was compared with MBM from mothers of term infants obtained at birth (tColostrum) and 3-4 weeks post delivery (tMBM). The microRNA profile in lipid and skim fractions of each sample was evaluated with high-throughput sequencing.ResultsThe expression profiles of nine microRNAs in lipid and skim pMBM differed from those in tMBM. Gene targets of these microRNAs were functionally related to elemental metabolism and lipid biosynthesis. The microRNA profile of tColostrum was also distinct from that of pMBM, but it clustered closely with tMBM. Twenty-one microRNAs correlated with gestational age demonstrated limited relationships with method of delivery, but not other maternal-infant factors.ConclusionPremature delivery results in a unique MBM microRNA profile with metabolic targets. This suggests that preterm milk may have adaptive functions for growth in premature infants.

Association of water handling and child feeding practice with childhood diarrhoea in rural community of Southern Nepal

Diarrhoea is a major cause of childhood morbidity and mortality globally. While the childhood diarrhoea and its association with child feeding, and hygiene, hand washing and water treatment are studied elsewhere, the association of water handling and child feeding with childhood diarrhoea is an understudied area in Nepal. This study aimed to investigate the association of water handling and child feeding practice with childhood diarrhoea among children of one to five years of age in Southern, Nepal. A cross-sectional study was conducted in the Dhanusha district of Southern Nepal in 2013. A total of 284 mother-child pairs were selected using systemic random sampling. A four-week prevalence of childhood diarrhoea was reported using frequency distribution. The association of childhood diarrhoea with water handling and child feeding practices was ascertained using multiple logistic regressions after adjusting for potential confounders. The result of the study demonstrated that the four-week prevalence of childhood diarrhoea was 36.6%. Our finding showed that unsafe water handling practices were associated independently with childhood diarrhoea: untreated water (aOR 3.55; 95% CI: 1.13-11.10), uncovered water (aOR 2.14; 95% CI: 1.09-4.19). Similarly, partial breast feeding (aOR 4.35; 95% CI: 1.87-10.12) was also associated with higher odds of childhood diarrhoea. One third of children in Southern Nepal still had diarrhoea within the four weeks preceding the survey. As poor water handling and sub optimal infant feeding practice were major risk factors contributing to such a high burden of the disease, health promotion strategies such as promotion of safe water handling, improved hygiene and child feeding practices are recommended for the prevention of childhood diarrhoea in Southern Terai of Nepal.

Association between Severe Dehydration in Rotavirus Diarrhea and Exclusive Breastfeeding among Infants at Dr. Hasan Sadikin General Hospital, Bandung, Indonesia

Background. Rotavirus is the leading cause of severe acute diarrhea in children. Infants who are exclusively breastfed develop fewer infections and have less severe illnesses. This study aimed to determine association between severe dehydration in rotavirus diarrhea and exclusive breastfeeding. Methods. This is a cross-sectional study in infants ≤ 6 months old with acute diarrhea in Dr. Hasan Sadikin Hospital, Bandung, Indonesia. Results. From 134 infants ≤ 6 months old with acute diarrhea enrolled from April 2009 to December 2012, there were 88 (65.6%) boys and 46 (34.4%) girls in this study. Rotavirus was detected in 60 (44.8 %), 32 (53.3%) of whom were exclusively breastfed. From rotavirus positive subjects, severe dehydration occurred in 4 (12.6%) exclusively breastfed infants and 6 (21.5%) not exclusively breastfed infants. No significant association was found between severe dehydration and exclusive breastfeeding (p = 0.491) in rotavirus diarrhea. Conclusions. In rotavirus diarrhea, there was no significant association between exclusive breastfeeding and severe dehydration.

Risk Factors Associated With Rotavirus Gastroenteritis During a Community Outbreak in Chiapas, Mexico During the Postvaccination Era

BACKGROUND

In January 2010, surveillance detected a rotavirus gastroenteritis outbreak in Chiapas, Mexico. We aimed to identify risk and protective factors for developing rotavirus gastroenteritis of any severity among children in the epidemic setting.

METHODS

A case-control study was conducted, comparing case patients (defined as children <36 months of age with acute gastroenteritis of any severity whose stool tested positive for rotavirus by enzyme immunoassay) with age- and municipality-matched controls. Information was obtained through face-to-face interviews on clinical outcome, demographics, breastfeeding history, rotavirus immunization status, and indicators of socioeconomic status.

RESULTS

Eighty-five case patients and 170 controls were enrolled. Factors associated with lower risk of rotavirus gastroenteritis included current breastfeeding, owning a refrigerator, and being immunized with 1 or 2 doses of a live-attenuated monovalent rotavirus vaccine. History of previous diarrheal episodes and living with 7 or more people in the same household were associated with higher risk of developing rotavirus gastroenteritis.

CONCLUSION

During this outbreak, dietary, socioeconomic, and environmental factors were independently associated with risk of developing rotavirus disease. Rotavirus vaccine also offered significant protection against rotavirus disease of any severity, emphasizing the value of vaccination as a simple and highly effective public health strategy for prevention of rotavirus illness.

Breastfeeding and the risk of rotavirus diarrhea in hospitalized infants in Uganda: a matched case control study

BACKGROUND

Rotavirus is responsible for over 25 million outpatient visits, over 2 million hospitalizations and 527,000 deaths annually, worldwide. It is estimated that breastfeeding in accordance with the World Health Organization recommendations would save 1.45 million children's lives each year in the developing countries. The few studies that examined the effect of breastfeeding on rotavirus diarrhea produced conflicting results. This study aimed to determine the effect of breastfeeding on rotavirus diarrhea among admitted infants in Uganda.

METHODS

The study was conducted in the Pediatrics medical emergency unit of a National Referral hospital during a peak incidence time for rotavirus from February to April 2008. It was an age matched case-control study with a ratio of 1:1. We consecutively enrolled infants presenting at the study site during this period whose caretakers consented to participate in the study. A minimum sample size of 90 pairs was adequate with power of 80% to detect a 30% decrease in breastfeeding rate among the cases assuming a breastfeeding rate of 80% in the controls. The infants with rotavirus positive results were the "cases". We used the commercial enzyme immunoassay kit (DAKO IDEIA™ rotavirus EIA detection kit) to diagnose the cases. The "controls" were admitted children with no diarrhea. We compared the cases and controls for antecedent breastfeeding patterns.

RESULTS

Ninety-one matched case-control age-matched pairs with an age caliper of one month were included in the analysis. Breastfeeding was not protective against rotavirus diarrhea (OR 1.08: 95% CI 0.52 - 2.25; p = 0.8) in the conditional logistic model.

CONCLUSIONS

Our study findings did not reveal breastfeeding as protective against rotavirus diarrhea in infants. This suggests searching for other complementary preventive methods such as rotavirus vaccination and zinc supplementation to reduce the problem of rotavirus diarrhea in infants irrespective of their feeding practices.

Breastfeeding protects against acute gastroenteritis due to rotavirus in infants

To assess whether breastfeeding protects against acute gastroenteritis (AGE) due to rotavirus (RV) infection compared to RV-negative AGE (RV-) in children age 0-12 months. Data from a community-based study of children with AGE from 30 pediatric practices in Germany, Switzerland, and Austria were evaluated. A case-control design was conducted with RV-positive AGE (RV+) cases and RV- AGE as controls. Odds ratios and 95% confidence intervals were estimated using log-linear regression models adjusting for child's age, family size, number of siblings, child care attendance, and nationality. A total of 1,256 stool samples were collected from infants with AGE; 315 (25%) were RV+ and 941 RV-. Being breastfed in the period of disease inception reduced the risk of AGE due to RV+ (OR, 0.53; 95% CI, 0.37-0.76). In infants 0-6 months of age, the protective effect was stronger (OR, 0.33; 95% CI, 0.19-0.55) than in 7-12-month-old children. Our study adds to the evidence of a protective concurrent effect of breastfeeding against rotavirus infection in infants, particularly in children 6 months and younger. Breastfeeding is important to diminish rotavirus-related gastroenteritis in infants before vaccination can be introduced.

Prevalence and factors associated with rotavirus infection among children admitted with acute diarrhea in Uganda

BACKGROUND

Rotavirus remains the commonest cause of severe dehydrating diarrhea among children worldwide. Children in developing countries die more because of several factors including poorer access to hydration therapy and greater prevalence of malnutrition. Hitherto, the magnitude of rotavirus disease in Uganda has remained unknown. This study was therefore done to determine the prevalence and factors associated with rotavirus infection among children aged 3-59 months admitted with acute diarrhea to paediatric emergency ward of Mulago Hospital, Uganda

METHODS

Three hundred and ninety children, aged between 3-59 months with acute diarrhoea were recruited. The clinical history, socio-demographic characteristics, physical examination findings and laboratory investigations were recorded. Stool samples were tested for rotavirus antigens using the DAKO IDEIA rotavirus EIA detection kit.

RESULTS

The prevalence of rotavirus infection was 45.4%. On multivariate analysis rotavirus was significantly associated with a higher education (above secondary) level of the mother [OR 1.8; 95% CI 1.1-2.7]; dehydration [OR 1.8; 95% CI 1.1-3.0] and breastfeeding [OR 2.6; 95% CI 1.4-4.0]. Although age was significantly associated with rotavirus on bivariate analysis; this association disappeared on multivariate analysis. No significant association was found between rotavirus infection and nutritional status, HIV status and attendance of day care or school.

CONCLUSIONS

Rotavirus infection is highly prevalent among children with acute diarrhoea admitted to Mulago Hospital in Uganda.

Antiinfective properties of human milk

The unfavorable effects of neonatal immunodeficiency are limited by some naturally occurring compensatory mechanisms, such as the introduction of protective and immunological components of human milk in the infant. Breast-feeding maintains the maternal-fetal immunological link after birth, may favor the transmission of immunocompetence from the mother to her infant, and is considered an important contributory factor to the neonatal immune defense system during a delicate and crucial period for immune development. Several studies have reported that breast-feeding, because of the antimicrobial activity against several viruses, bacteria, and protozoa, may reduce the incidence of infection in infants. The protection from infections may be ensured either passively by factors with antiinfective, hormonal, enzymatic, trophic, and bioactive activity present in breast milk, or through a modulator effect on the neonatal immune system exerted by cells, cytokines, and other immune agents in human milk.

Session 1: Public health nutrition Breast-feeding practices in Ireland

Breast-feeding is the superior infant feeding method from birth, with research consistently demonstrating its numerous short- and long-term health benefits for both mother and infant. As a global recommendation the WHO advises that mothers should exclusively breast-feed for the first 6-months of life, thus delaying the introduction of solids during this time. Historically, Irish breast-feeding initiation rates have remained strikingly low in comparison with international data and there has been little improvement in breast-feeding duration rates. There is wide geographical variation in terms of breast-feeding initiation both internationally and in Ireland. Some of these differences in breast-feeding rates may be associated with differing socio-economic characteristics. A recent cross-sectional prospective study of 561 pregnant women attending a Dublin hospital and followed from the antenatal period to 6 months post partum has found that 47% of the Irish-national mothers initiated breast-feeding, while only 24% were still offering ‘any’ breast milk to their infants at 6 weeks. Mothers' positive antenatal feeding intention to breast-feed is indicated as one of the most important independent determinants of initiation and ‘any’ breast-feeding at 6 weeks, suggesting that the antenatal period should be targeted as an effective time to influence and affect mothers' attitudes and beliefs pertaining to breast-feeding. These results suggest that the ‘cultural’ barrier towards breast-feeding appears to still prevail in Ireland and consequently an environment that enables women to breast-feed is far from being achieved. Undoubtedly, a shift towards a more positive and accepting breast-feeding culture is required if national breast-feeding rates are to improve.

Dietary nucleotides and fecal microbiota in formula-fed infants: a randomized controlled trial

BACKGROUND

Dietary nucleotides are nonprotein nitrogenous compounds that are thought to be important for growth, repair, and differentiation of the gastrointestinal tract. A higher nucleotide intake may also have favorable effects on the fecal microbial composition and incidence of diarrhea in infancy. However, few studies have tested this hypothesis with an experimental study design.

OBJECTIVE

We tested the hypothesis that nucleotide supplementation of infant formula has beneficial effects on fecal bacteriology.

DESIGN

Oligonucleotide probes were used to measure bacterial genus-specific 16S ribosomal RNA in stools of a subset of infants (mean age: 20.4 wk) who were randomly assigned to nucleotide-supplemented (31 mg/L; n = 35) or control formula (n = 37) from birth until age 20 wk or were breastfed (reference group; n = 44). The microbial pattern was assessed as the ratio of Bacteroides-Porphyromonas-Prevotella group (BPP) to Bifidobacterium species.

RESULTS

The ratio of BPP to Bifidobacterium spp. rRNA in infants randomly assigned to the nucleotide-supplemented formula was lower than in infants receiving the control formula (mean difference: -118%; 95% CI: -203%, -34%; P = 0.007), but it did not differ in infants who were breastfed. The difference between randomized formula-fed groups was independent of potential confounding factors (P = 0.003).

CONCLUSIONS

Our data support the hypothesis that nucleotide supplementation improves the composition of the gut microbiota in formula-fed infants. Because this effect could contribute to previously described benefits of nucleotide supplementation for gastrointestinal tract and immune function, these findings have important implications for optimizing the diet of formula-fed infants.

Lysozyme transgenic goats' milk influences gastrointestinal morphology in young pigs

Transgenesis provides a method of expressing novel proteins in milk to increase the functional benefits of milk consumption. Transgenic goats expressing human lysozyme (hLZ) at 67% of the concentration in human breast milk were produced, thereby enhancing the antimicrobial properties of goats' milk. The objective of this study was to investigate the impact of pasteurized milk containing hLZ on growth, the intestinal epithelium, and an enteropathogenic Escherichia coli (EPEC) infection in young weaned pigs. Pigs were placed into 4 groups and fed a diet of solid food and either control (nontransgenic) goats' milk or milk from hLZ-transgenic goats. Growth was assessed by weight gain. Nonchallenged pigs were necropsied after 6 wk, whereas the remaining pigs were necropsied at 7 wk following bacterial challenge. We determined the numbers of total coliforms and E. coli and examined small intestinal histology for all pigs. Complete blood counts were also determined pre- and postchallenge. Challenged pigs receiving hLZ milk had fewer total coliforms (P = 0.029) and E. coli (P = 0.030) in the ileum than controls. hLZ-fed pigs also had a greater duodenal villi width (P = 0.029) than controls. Additionally, nonchallenged hLZ-fed pigs had fewer intraepithelial lymphocytes per micron of villi height (P = 0.020) than nonchallenged controls. These results indicate that the consumption of pasteurized hLZ goats' milk has the potential to improve gastrointestinal health and is protective against an EPEC in young weaned pigs. These same benefits may occur in young children if they were to consume milk from hLZ-transgenic goats.

Undernutrition, infection and immune function

Undernutrition and infection are the major causes of morbidity and mortality in the developing world. These two problems are interrelated. Undernutrition compromises barrier function, allowing easier access by pathogens, and compromises immune function, decreasing the ability of the host to eliminate pathogens once they enter the body. Thus, malnutrition predisposes to infections. Infections can alter nutritional status mediated by changes in dietary intake, absorption and nutrient requirements and losses of endogenous nutrients. Thus, the presence of infections can contribute to the malnourished state. The global burden of malnutrition and infectious disease is immense, especially amongst children. Childhood infections impair growth and development. There is a role for breast-feeding in protection against infections. Key nutrients required for an efficient immune response include vitamin A, Fe, Zn and Cu. There is some evidence that provision of the first three of these nutrients does improve immune function in undernourished children and can reduce the morbidity and mortality of some infectious diseases including measles, diarrhoeal disease and upper and lower respiratory tract infections. Not all studies, however, show benefit of single nutrient supplementation and this might be because the subjects studied have multiple nutrient deficiencies. The situation regarding Fe supplementation is particularly complex. In addition to immunization programmes and improvement of nutrient status, there are important roles for maternal education, improved hygiene and sanitation and increased supply of quality water in the eradication of infectious diseases.

A case-control study of the epidemiology of sporadic Salmonella infection in infants

OBJECTIVE

Rates of Salmonella infection are highest in infants, but little is known about potential sources of infection in this high-risk population. We performed a case-control study to identify dietary and environmental risk factors for sporadic salmonellosis among infants.

PATIENTS AND METHODS

In 2002-2004, the Foodborne Diseases Active Surveillance Network conducted a population-based, case-control study of sporadic salmonellosis among infants <1 year of age in 8 states. Cases were identified via active laboratory-based surveillance. Healthy controls were frequency matched by age and identified through birth registries or published birth announcements. We assessed diet and environmental exposures in the 5 days before illness onset or interview. Data were analyzed by using logistic regression adjusting for age.

RESULTS

The study enrolled 442 subjects and 928 controls. Compared with healthy controls, infants with Salmonella infection were less likely to have been breastfed and more likely to have had exposure to reptiles, to have ridden in a shopping cart next to meat or poultry, or to have consumed concentrated liquid infant formula during the 5-day exposure period. Travel outside the United States was associated with illness in infants 3 to 6 and >6 months of age. Attending day care with a child with diarrhea was associated with salmonellosis in infants >6 months of age.

CONCLUSIONS

We identified a number of modifiable protective and risk factors for salmonellosis in infants. Attention should be directed at developing effective preventive measures for this high-risk population.

How protective is breast feeding against diarrhoeal disease in infants in 1990s England? A case-control study

AIMS

To assess the effect of several measures of infant feeding on diarrhoeal disease, and whether these effects vary according to markers of social deprivation.

METHODS

Case-control study of diarrhoeal disease cases presenting to 34 general practices in England. Controls were stratified on age group, area deprivation index for the practice, and whether or not the practice was in London. Data were available on 304 infants (167 cases and 137 controls).

RESULTS

After adjustment for confounders, breast feeding was associated with significantly less diarrhoeal disease. Associations were striking even in infants aged > or = 6 months. They did not vary by social class, but were greater in those living in rented council accommodation and in more crowded households. The effect of receiving no breast milk was stronger in more deprived areas than in less deprived areas. The effect of not receiving exclusive breast milk was stronger in more deprived areas than in less deprived areas. In formula fed infants, there was significantly more diarrhoeal disease in those not sterilising bottles/teats with steam or chemicals. The protective effect of breast feeding did not persist beyond two months after breast feeding had stopped.

CONCLUSIONS

Breast feeding protects against diarrhoeal disease in infants in England although the degree of protection may vary across infants and wear off after breast feeding cessation. Education about the benefits of breast feeding and the risks of inadequate sterilisation should be targeted at carers in deprived areas or households.

Effects of intestinal microflora and the environment on the development of asthma and allergy

The aim of previous research into the causes of allergic diseases, including asthma was mostly to identify potential risk factors in the environment. No major risk factors have been identified, however. Over the past 10 years, focus has, therefore, more been directed towards protective factors that could enhance the development of tolerance to allergens which were previously encountered early in life, but are now lost in modern affluent societies. In particular, the role of childhood infections has been discussed, but so far these studies have not been conclusive. Recent epidemiological studies and experimental research suggest that the microbial environment and exposure to microbial products in infancy modifies immune responses and enhances the development of tolerance to ubiquitous allergens. The intestinal microflora may play a particular role in this respect, as it is the major external driving force in the maturation of the immune system after birth, and animal experiments have shown it to be a prerequisite for normal development of oral tolerance. Recent studies have shown differences in the composition of the microflora between healthy and allergic infants in countries with a high and low prevalence of allergies and between healthy and allergic infants within such countries. These differences are apparent within the first week of life and thus precede clinical symptoms. The use of live microorganisms that might be beneficial to health has a long tradition and the safety is well documented. Very recently, several prospective intervention studies, modifying the gut flora from birth have yielded encouraging results and may suggest a new mode of primary prevention of allergy in the future.

Caesarean section increases the risk of hospital care in childhood for asthma and gastroenteritis

OBJECTIVE

To investigate if caesarean section (CS) increases the risk for childhood asthma and gastroenteritis with reference made to children born with vaginal delivery (VD).

METHODS

Retrospective study of data from linked Swedish medical service registers--Medical Birth Registry (MBR) and Hospital Discharge Registry (HDR). Data were obtained from women without any background/perinatal morbidity noted, and from children without any neonatal complications. Children that had reached at least 1 year of age and were found in the HDR were considered as cases, whereas children not found in the HDR or hospitalized for other causes than asthma or gastroenteritis were defined as controls. Odds ratios (OR) stratified for year of birth, maternal age, parity and smoking in early pregnancy were calculated. Investigations were made comparing the risk for in hospital treatment for asthma or gastroenteritis in CS children and in VD siblings of CS children. The overall inpatient morbidity in CS and VD children were also investigated.

RESULTS

The OR for asthma in CS children was 1.31 [95% confidence interval (CI) 1.23-1.40]. The same OR, 1.31, was found for gastroenteritis (95% CI 1.24-1.38). The OR for CS children having experienced both asthma and gastroenteritis was further increased (1.74, 95% CI 1.36-2.23). The risk for asthma in VD siblings of CS children was not significantly increased, whereas VD siblings experienced a slightly increased risk for gastroenteritis. CS children had an increased overall in hospital morbidity when compared to VD children.

CONCLUSION

There is a significant increase of the risk for developing symptoms of asthma and/or gastroenteritis that motivates admission for hospital care in CS children older than 1 year. It is speculated that a disturbed intestinal colonization pattern in CS children may be a common pathogenic factor.

PCDDs, PCDFs, and PCBs concentrations in breast milk from two areas in Korea: body burden of mothers and implications for feeding infants

We determined breast milk concentration of polychlorinated dibenzo-p-dioxins (PCDDs)/polychlorinated dibenzofurans (PCDFs) and polychlorinated biphenyls (PCBs) in 24 mothers living in Korea, and assessed the maternal body burden based on PCDDs/PCDFs and PCBs concentrations in breast milk and an infant intake rate through breast-feeding based on their concentration in breast milk. PCDDs/PCDFs and PCBs levels in breast milk from primipara mothers were found to be higher than those from multipara mothers. For total PCDDs/PCDFs TEQ level, 2,3,4,7,8-PeCDD was the predominant congener, and the proportion of 2,3,7,8-TCDD was less than 3% of total PCDDs/PCDFs TEQ level. For PCBs TEQ level, PCB-126 was the predominant congener. Maternal body burden levels of PCDDs/PCDFs and PCBs based on their concentrations in breast milk were 268-622 TEQ ng. The daily dioxin intakes of mothers were predicted to be 0.78-2.18 TEQ pg/kg/day for PCDDs/PCDFs and 0.34-0.66 TEQ pg/kg/ day for PCBs. For the first year, the body burden of an infant was predicted to be 212 TEQ ng and the daily intake of an infant was predicted to be 85 TEQ pg/kg/day, assuming the mean dioxin-related compounds concentration (27.54 TEQ pg/g fat).

Human milk provides peptides highly stimulating the growth of bifidobacteria

The large intestine of breast-fed infants is colonized predominantly by bifidobacteria, which have a protective effect against acute diarrhea. In this study we report for the first time the identification of human milk peptides that selectively stimulate the growth of bifidobacteria. Several bifidogenic peptides were purified chromatographically from pepsin-treated human milk and identified as proteolytically generated fragments from the secretory component of the soluble polyimmunoglobulin receptor and lactoferrin; both of these proteins exhibit antimicrobial effects. Hydrolysis of the identified peptides with the gastrointestinal proteases pepsin, trypsin and chymotrypsin did not lead to the loss of bifidogenic activity, indicating their potential function in vivo. Sequential comparison revealed a similar structural motif within the identified peptides. A correspondingly designed small peptide (prebiotic lactoferrin-derived peptide-I, PRELP-I) was found to stimulate the growth of bifidobacteria as effectively as the native peptides. The combination of antimicrobial and bifidobacterial growth stimulatory activity in human milk proteins leads to highly specific compounds capable of regulating the microbial composition of infants' large intestine.

Position of the American Dietetic Association: breaking the barriers to breastfeeding

It is the position of the American Dietetic Association (ADA) that broad-based efforts are needed to break the barriers to breastfeeding initiation and duration. Exclusive breastfeeding for 6 months and breastfeeding with complementary foods for at least 12 months is the ideal feeding pattern for infants. Increases in initiation and duration are needed to realize the health, nutritional, immunological, psychological, economical, and environmental benefits of breastfeeding. Breastfeeding initiation rates have increased, but cultural barriers to breastfeeding, especially against breastfeeding for 6 months and longer, still exist. Gaps in rates of breastfeeding based on age, race, and socioeconomic status remain. Children benefit from the biologically unique properties of human milk including protection from illness with resulting economic benefits. Mother's benefits include reduced rates of premenopausal breast and ovarian cancers. Appropriate lactation management is a critical component of successful breastfeeding for healthy women. Lactation support and management is even more important in women and children with special needs caused by physical or developmental disability, disease, or limited resources. Dietetics professionals have a responsibility to support breastfeeding through appropriate education and training, advocacy, and legislative action; through collaboration with other professional groups; and through research to eliminate the barriers to breastfeeding.

Early nutrition and the development of immune function in the neonate

The present review will concentrate on the development of the gut-associated lymphoid tissue and the role of early nutrition in promoting immune function. The intestine is the largest immune organ in the body, and as such is the location for the majority of lymphocytes and other immune effector cells. The intestine is exposed to vast quantities of dietary and microbial antigens, and is the most common portal of entry for pathogens, some of which are potentially lethal. The development of normal immune function of the intestine is therefore vital for survival, and is dependent on appropriate antigen exposure and processing, and also an intact intestinal barrier. In early life innate mechanisms of defence are probably more important than active or adaptive mechanisms in responding to an infectious challenge, since the healthy neonate is immunologically naïve (has not seen antigen) and has not acquired immunological memory. During this period maternal colostrum and milk can significantly augment resistance to enteric infections. The mechanisms of enhancing disease resistance are thought to be passive, involving a direct supply of anti-microbial factors, and active, by promoting the development of specific immune function. A tolerance response to dietary and non-invasive antigens is generally induced in the gut. However, it must also be able to mount an adequate immune response to ensure clearance of foreign antigens. It is now recognized that regulation of tolerance and active immune responses is critical to health, and failure to regulate these responses can lead to recurrent infections, inflammatory diseases and allergies. The education of the immune system in early life is thought to be critical in minimizing the occurrence of these immune-based disorders. During this phase of development maternal milk provides signals to the immune system that generate appropriate response and memory. One factor that has been proposed to contribute to the increase in the incidence of immune-based disorders, e.g. atopic diseases in Western countries, is thought to be the increased prevalence of formula-feeding.

A folding variant of alpha-lactalbumin with bactericidal activity against Streptococcus pneumoniae

This study describes an alpha-lactalbumin folding variant from human milk with bactericidal activity against antibiotic-resistant and -susceptible strains of Streptococcus pneumoniae. The active complex precipitated with the casein fraction at pH 4.6 and was purified from casein by a combination of anion exchange and gel chromatography. Unlike other casein components, the active complex was retained on the ion-exchange matrix and eluted only with high salt. The eluted fraction showed N-terminal and mass spectrometric identity with human milk alpha-lactalbumin, but native alpha-lactalbumin had no bactericidal effect. Spectroscopic analysis demonstrated that the active form of the molecule was in a different folding state, with secondary structure identical to alpha-lactalbumin from human milk whey, but fluctuating tertiary structure. Native alpha-lactalbumin could be converted to the active bactericidal form by ion-exchange chromatography in the presence of a cofactor from human milk casein, characterized as a C18:1 fatty acid. Analysis of the antibacterial spectrum showed selectivity for streptococci; Gram-negative and other Gram-positive bacteria were resistant. The folding variant of alpha-lactalbumin is a new example of naturally occurring molecules with antimicrobial activity.

Nutritional management in diarrhoeal disease

Adequate nutritional intervention in diarrhoeal disease in children is crucial in obtaining optimal control of a disorder that may become life-threatening. During recent years, important advances have been made in our understanding of the pathophysiology of diarrhoeal states, in the formulation of oral rehydration solutions and in the role of micro- and macronutrients in diarrhoeal disorders. This chapter outlines some of the relevant concepts in the pathophysiology of diarrhoeal disease and provides a rationale for nutritional intervention. Guidelines for nutritional management in the settings of acute-onset diarrhoea, post-enteritis protracted diarrhoea and chronic non-specific diarrhoea are provided, mostly based on controlled clinical trials and meta-analyses of evidence-based medicine.

Breast feeding and infant mortality

The evidence linking bottle feeding to infant and early childhood mortality has been reviewed. Ecological studies of national time trends in infant mortality do not parallel breast feeding trends in those countries, and indicate that falling death rates are more likely to be related to better health care facilities and social conditions. Direct studies of deaths provide some contradictory findings; meta-analyses are not informative because of the many differences in statistical and sample methodology. The methodology exhibited in most studies is more likely to have over- rather than under-estimated a relationship between bottle feeding and infant mortality. Retrospective analyses must take account of changes in feeding pattern due to early signs of illness. Prospective population studies able to account for large numbers of potential confounders provide the best estimates, especially if proportional hazards models are used. Two such studies have been carried out--both showed protective effects of breast feeding.

The incidence and duration of breast feeding

Information obtained from a variety of sources shows different rates of initiation and duration of breast feeding and different supplementation strategies. Among populations of developing countries, in general, the mothers resident in rural-areas are more likely to breast feed than those in urban areas; in addition the better off or more highly educated are less likely to breast feed. In contrast in the developed countries, the better educated and the higher social class mothers are more likely to breast feed. There is some evidence that delay in initiation of breast feeding, lack of professional support, conflicting advice from health professionals and the presence of free samples of artificial milk (whether or not given to the mother) can result in a mother failing to establish breast feeding. Additionally, mothers who smoke cigarettes are less likely to breast feed successfully. Whilst breast feeding is almost universal in a number of developing countries, many also commonly use complementary feeds. In some countries, particularly in Asia, it is still commonplace for a child not to be given the mother's colostrum, and therefore for the first breast feed to occur well after the first 24 h.

The growth and nutritional status of the breast-fed infant

The literature on the relationship between early infant feeding and growth shows that after the first 3 or 4 months, breast-fed infants in the developed world are lighter than formula-fed infants with markedly lower adiposity. There is some evidence of a slightly lower rate of linear growth over the first year or so. These differences in weight and length do not apparently persist beyond the first few years of life. In the developing world the situation is very different. The growth curves of breast-fed infants of malnourished mothers may falter between the third and sixth month of life. However, the generally poor quality of the supplementary foods offered in the developing world and the increased risk of diarrhoeal infections mean that supplementary feeding before the age of 6 months is unlikely to lead to a growth advantage and may well lead to growth faltering.

Properties of human milk and their relationship with maternal nutrition

The composition of human milk varies over the course of lactation and in each individual. The volume of breast milk produced is related to the weight of the infant. Human milk is markedly different from cows' milk, both in terms of macronutrients and micronutrients. This includes the types of fatty acids present and factors affecting their absorption. The types of proteins present and their relative proportions and both qualitative and quantitative differences in the non-protein nitrogen fraction. There is much less lactose in cows' milk than breast milk and the oligosaccharide fraction is very different. Their are major differences in content and absorption rates of vitamins and minerals from breast milk compared to cows' milk or formula milk. Vitamin D and vitamin K status are possible problems for the breast-fed infant in certain circumstances. The nutritional status of the mother appears to influence fat concentration and thus the energy content of breast milk as well as its fatty acid composition and immunological properties. There is no coherent evidence, however, that the protein or lactose concentrations are greatly affected. There is some evidence that the concentration of vitamins in the breast milk are influenced by the mother's intake. Minerals are less variable, with the exception of selenium. The response of the infant to human and formula milk differs with respect to endocrine function, stool motility, immune function and renal function. Infant formula milks are designed to mimic human milk as much as possible, but this is unlikely to ever be completely successful. A number of important compositional differences between human milk and formula milk remain. This includes the types and proportions of fatty acids present (which may be of developmental importance), the nature of the non-protein nitrogen component (also possible developmental importance) and the presence of immunoglobulins and fibronectin (which may protect the infant against infection).

Does breast feeding protect against non-gastric infections?

There is convincing evidence that breast-feeding is protective against gastro-enteritis and diarrhoea, but for other infections the situation is less clear cut. There is evidence that breast-fed infants are at increased risk of one infection (infant botulism). They are probably not significantly protected from upper respiratory tract infections (other than otitis media.), but they may be at a decreased risk of lower respiratory tract infections, particularly those associated with respiratory syncytial virus. There is strong evidence that Haemophilus influenzae B infection is more likely in the bottle-fed infant, and consistent evidence of protection of young children from chronic otitis media with prolonged breast-feeding.