Young Child Formula: A Position Paper by the ESPGHAN Committee on Nutrition

Research on commercial milk formulas for young children: A scoping review

A scoping review of publications about commercial milk formulas intended for or consumed by children 12-36 months (CMF 12-36) was conducted. This review aimed to comprehensively map the existing literature, identify key concepts in the field and understand its evolution through time. A total of 3329 articles were screened and 220 were included, published between 1986 and 2024. Most works were published after 2016 (70.0%) and in high-income countries (71.8%). Original studies were the vast majority (81.8%) of publications. Most publications dealt with feeding practices or analysed the composition and/or contamination of specific products (44.1% and 35.9%), but since the late 2000s, publications about marketing, policy, legislation, and consumer perception started to appear. Most published works (65.5%) did not focus exclusively on CMF 12-36 and included formulas for other demographics or other foods. About half of the works (55.5%) did not consider CMF 12-36 to be a breast milk substitute. We found 81 distinct product denominations used to refer to CMF 12-36, Growing Up Milk was the most common (25.9%). CMF industry was involved in 41.8% of all analysed works, and industry participation and funding were not always clearly informed (22.5% lacked a conflict of interest statement, and 25.5% did not present any information about funding). In the last decade, publications about CMF 12-36 have increased in volume and diversified in scope and subject matter. CMF-industry participation has always been and still is present in the field, so possible vested interests should be taken into account when appreciating the literature.

World Health Organization (WHO) guideline on the complementary feeding of infants and young children aged 6-23 months 2023: A multisociety response

The recent World Health Organization (WHO) guideline aims to provide evidence-based recommendations on complementary feeding (CF) of healthy term infants and young children 6-23 months living in low-, middle-, and high-income countries, including both breastfed and non-breastfed children. Like WHO, our organizations aim to promote optimal infant and young child nutrition and health, with a focus on promoting breastfeeding as well as appropriate and timely CF. In this paper, we share our concerns about aspects of the guideline, some of which may have the potential to cause unintended harm in infants and young children and suggest alternative or modified proposals.

Pediatric Formulas: An Update

The recent shortage of pediatric formulas in the United States, caused by supply chain issues and contamination of formula products in 1 of the major manufacturing plants, led many families to seek an alternate formula for their children. The Food and Drug Administration (FDA) allowed import of infant formulas from selected European and non-European countries. The European infant formulas differ from those produced in the United States regarding the primary source of the formula, age category, mixing instructions, labeling requirements, and formula composition in terms of macronutrients and micronutrients. Although most European infant formulas are nutritionally adequate, pediatricians and families need to be aware of the differences between the European and FDA-regulated formulas for their correct use and preparation for infants and young children. Supplementation with cow milk is recommended for children beyond infancy, and older infant formulas are not recommended for otherwise healthy growing children. However, pediatric formulas have been used to support the nutrition needs of children with feeding difficulties, especially those dependent on tube feeding and with certain medical conditions. The FDA does not regulate the production of pediatric formulas beyond infant formula, and significant variations exist in their composition. The pediatric formulas are available as polymeric (intact), hydrolyzed, elemental, or food-based blenderized formulas. The plant-based nonformula (milk) drinks are being used increasingly for children. These products might not be nutritionally complete and should be avoided in infants and children dependent on liquid nutrition.

Reply to Benedik et al. Comment on "Jakše et al. Vegan Diets for Children: A Narrative Review of Position Papers Published by Relevant Associations. Nutrients 2023, 15, 4715"

Benedik et al [...].

Infant feeding-a scoping review for Nordic Nutrition Recommendations 2023

The 2012 edition of the Nordic Nutrition Recommendations (NNR) included recommendations on breastfeeding, based on the most recent guidelines and recommendations from major national food and health authorities and organizations, systematic reviews, and some original research. For NNR 2023, the scope has been expanded and also includes formula feeding and the introduction of solid food. The main focus in this scoping review is on infants aged 0-12 months but also considers parts both before and beyond the first year, as the concept of 'the first 1000 days' emphasizes the importance of factors during pregnancy and the first 2 years of life for immediate and later health: physical as well as emotional and mental health. Breastmilk is the natural and sustainable way to feed an infant during the first months of life. Numerous studies have indicated immediate as well as long-term beneficial effects of breastfeeding on health for both the infant and the breastfeeding mother, and from a public health perspective, it is therefore important to protect, support, and promote breastfeeding. For full-term, normal weight infants, breastmilk is sufficient as the only form of nutrition for the first 6 months, except for vitamin D that needs to be given as supplement. The World Health Organization (WHO) and several other authoritative bodies therefore recommend exclusive breastfeeding during the first 6 months. Starting solids at about 6 months is necessary for both nutritional and developmental reasons. According to the European Food Safety Authority (EFSA) and the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN), solid foods are safe to give from 4 months although exclusive breastfeeding until 6 months is the desirable goal. Breastfeeding can continue together with complementary foods as long as it is mutually desired by the mother and child. If breastfeeding is not enough or for some reason discontinued before the infant is 4 months of age, the infant should be fed infant formula, and, when possible, breastfeeding should be continued alongside the formula feeding. If the infant is 4 months or older, starting with solids together with continued breastfeeding and/or formula feeding is an option. Infant formulas have been developed for infants who are not breastfed or do not get enough breastmilk. Home-made formula should not be given.

Micronutrient intake inadequacies in different types of milk consumers in Indonesian children 1–5 years: dietary modeling with young child milk improved nutrient intakes

Background

Indonesian children under-five have a high prevalence of micronutrient deficiencies. Improving young child feeding practices may be the solution. Increasing the consumption of appropriate milk products could help to reduce nutrient inadequacy.

Methods

The objective of this study was to assess nutrient inadequacy in Indonesian children to evaluate the potential improvement using dietary modeling analysis. Data from children aged 1-5 years from the Indonesian Individual Dietary Consumption Survey in 2014 were used in this analysis (n = 11,020). Diet modeling was conducted in two scenarios, substitution volume to volume and calories to calories.

Results

The proportion of children consuming young child milk (YCM) was the highest compared to other milk types across all age groups, followed by condensed milk and cow's milk. YCM, also called "Growing-Up Milk" (GUM), are marketed as a product specifically formulated for the nutritional needs of young children. YCM consumers had lower prevalence of inadequate intakes in iron, zinc, vitamins A, C and D across age groups when compared to condensed milk consumers. The prevalence of inadequate intakes of nutrients in condensed milk consumers was Vitamin A (67, 64%), folate (92, 91%), Vitamin D (87, 84%), iron (84, 76%), and zinc (76, 76%) in 1-2y and 3-4y, respectively. The substitution of condensed milk with a YCM reduced the prevalence of inadequate intakes of micronutrients, such as Vitamin A, vitamin D, folate, iron and zinc, which are important for immune function. YCM reduced the prevalence of inadequate intakes of micronutrients by 20-40% (Vit A and folate) and 40-50% (Vit D and zinc). The reduction of prevalence of inadequate iron intake was 31% in 1-2y and 63% in 3-4y.

Conclusion

The prevalence of inadequate micronutrient intakes was high among children aged 1-5 years old in Indonesia. YCM consumers had better nutrient intake. The substitution of condensed milk with a YCM reduced the prevalence of inadequate of micronutrient intake. Thus, nutrient intakes could be improved by YCM consumption in 1-5 years old children in Indonesia, along with nutrition education on feeding practices.

Plant-Based Milk Alternatives in Child Nutrition

Plant-based milk alternatives can be distinguished in two main categories, differing in production processes and regulation: plant-based formulas and plant-based drinks. They are now a widely accepted class of products on the international market. The various plant-based milk alternatives differ in nutritional characteristics due to their origin and manufacturing; more importantly, whereas formulas from plant and cow origin can be used interchangeably, plant-based drinks are nutritionally different from cow's milk and can be consumed by children subsequently to the use of formula. Several scientific organizations have expressed differing opinions on the use of these products in the diets of children. In the face of unanimous conclusions regarding the use of these products during the first year of life, in subsequent ages there were conflicting opinions regarding the timing, quantities, and type of product to be used. From the viewpoint of the child's overall diet and health, it could be suggested that these foods be considered not as simple substitutes for cow's milk, but as part of a varied diet, within individual advice of use. We suggest accepting the presence of these products in a baby's diet (omnivores included), planning their use correctly in the context of a balanced diet, according to the specific product and the needs of the individual.

Nutrition Content of Young Child Formulas

OBJECTIVE

European Society for Pediatric Gastroenterology, Hepatology and Nutrition and the American Academy of Pediatrics state that young child formula (YCF) is not considered necessary for healthy children. Despite these recommendations, YCF accounts for approximately 13% of overall formula sales. Five percent of infants less than 1 year of age in the United States are being fed YCF. The purpose of this study is to identify the most Internet recommended and encountered YCF in the United States and determine if they meet nutritional recommendations for use in children 0-3 years.

STUDY DESIGN

We used the search terms "toddler formula," "toddler milk," "follow-up formula," or "young child formula" in Google and DuckDuckGo to identify the most like encountered or recommended YCF on the Internet. We compared their labeled nutrients to Food and Drug Administration (FDA) Infant Formula Act (IFA) and international nutrient recommendations, given the absence of US nutrient requirements for YCF recommendations, for children 12-36 months.

RESULTS

Twenty-nine YCF were reviewed. On average, YCF did not meet nutrient recommendations for infants and toddlers with 2.17 and 4.6 ingredients not meeting formula recommendations for younger and older infants, respectively, and between 3 and 4 ingredients for 12-36 months.

CONCLUSIONS

Nutrition content of YCF are variable and do not meet FDA IFA requirements or YCF international recommendations. Increased US regulation is needed for YCF. It is important for health care providers to ask patients what they are feeding their infants and toddlers so they can educate parents on potential nutritional safety concerns.

Evaluation and Management of Pediatric Feeding Disorder

Feeding disorders are increasingly common in children, especially as medical advancements improve the life expectancy of children born with prematurity and complex medical conditions. The most common symptoms include malnutrition, refusal to eat and drink, food pocketing, disruptive feeding behavior, slow feeding, food selectivity or rigid food preferences, limited appetite, and delayed feeding milestones. A unifying diagnostic definition of pediatric feeding disorder has been proposed by a panel of experts to improve the quality of health care and advance research. Referral to specialized care should be considered when feeding problems are complex or difficult to resolve. In this review, we provide an overview of the evaluation and management of pediatric feeding disorders and information that may be useful when considering whether referral to specialized care may be beneficial.

Effect of Fortified Formula on Growth and Nutritional Status in Young Children: A Systematic Review and Meta-Analysis

Previous reviews of the effect of young child formulas on health outcomes in infants and toddlers have been inconclusive. In this study, we undertook a contemporary synthesis of studies investigating the effects of consuming fortified milk beverages (compared to cow’s milk or unfortified comparator formula) on growth and/or nutritional status in children 1−3 years of age. Five electronic databases were searched (PubMed, Web of Science, Scopus, ProQuest, and Cochrane Library) for randomised controlled trials comparing fortified milk against control milk in young children (9−48 months), published between January 1990 and June 2022. Outcomes were growth, body composition, biochemical markers, and/or nutritional status. Mean differences (MD) were pooled using random-effects meta-analysis where there were ≥3 studies. The risk of bias was assessed using the Cochrane Risk of Bias 2.0 tool. Nineteen articles (12 studies; n = 4795) met the inclusion criteria. Heterogeneity was substantial, likely attributable to considerable variation in study characteristics. Fortified milk was associated with increased weight gain (MD = 0.14 kg [95% CI 0.06, 021], p = 0.0003) compared with control milk. Subgroup analyses demonstrated increases in weight in lower-income countries, and in studies with intervention periods > 6 months. There were no effects of fortified milks on other anthropometric measures. Haemoglobin (MD = 3.76 g/L [95% CI 0.17, 7.34], p = 0.04) and ferritin (MD = 0.01 nmol/L [95% CI 0.00, 0.02], p = 0.02) concentrations were increased in infants consuming fortified milks. Fortified milk beverages appear to offer a safe and acceptable source of complementary nutrition as a short-term strategy for addressing nutritional deficits and may modestly promote weight gain in vulnerable populations when provided for periods > 6 months. This study was prospectively registered with PROSPERO (CRD42022339920) and funded by the Infant Nutrition Council.

Dietary Intake, Nutritional Adequacy, and Food Sources of Selected Antioxidant Minerals and Vitamins; and Their Relationship with Personal and Family Factors in Spanish Children Aged 1 to <10 Years: Results from the EsNuPI Study

Minerals and vitamins involved in the antioxidant defense system are essential for healthy growth and proper development during infancy. Milk and dairy products are of particular importance for improving the supply of these nutrients to children. Indeed, the present study aimed to evaluate the nutrient intake and food sources of zinc (Zn), selenium (Se), retinol and carotenoids (sources of vitamin A), and vitamins C and E, and to analyze their relationships with personal and familiar factors in Spanish children from the EsNuPI study. One subpopulation representative of the Spanish population from 1 to <10 years old (n = 707) (reference group, REF) who reported consuming all types of milk over the last year, and another subpopulation of the same age who reported consuming fortified milk formulas (FMFs) (including follow-on formula, young child formula, growing up milk, toddler’s milk, and enriched and fortified milk) (n = 741) (fortified milk consumers, FMCs) completed two 24 h dietary recalls used to estimate their nutrient intakes and to compare them to the European Food Safety Authority (EFSA) Dietary Reference Values (DRVs). The REF reported higher median intakes than FMCs for Se (61 µg/kg vs. 51 µg/kg) and carotenoids (1079 µg/day vs. 998 µg/day). Oppositely, FMCs reported higher intakes than REF for Zn (7.9 mg/day vs. 6.9 mg/day), vitamin A (636 µg/day vs. 481 µg/day), vitamin E (8.9 mg/day vs. 4.5 mg/day), vitamin C (113 mg/day vs. 71 mg/day), and retinol (376 µg/day vs. 233 µg/day). In the REF group, more than 50% of the children met the EFSA recommendations for Zn (79.6%), Se (87.1%), vitamin A (71.3%), and vitamin C (96.7%), respectively. On the other hand, 92.2% were below the EFSA recommendations for vitamin E. In the FMC group, more than 50% of the children met the EFSA recommendations for Zn (55.2%), Se (90.8%), vitamin A (75.7%), vitamin E (66.7%), and vitamin C (100%). We found statistically significant differences between subpopulations for all cases except for Se. In both subpopulations, the main sources of all antioxidant nutrients were milk and dairy products. For carotenoids, the main sources were vegetables and fruits followed by milk and dairy products. A high percentage of children had vitamins A and E intakes below the recommendations, information of great importance to stakeholders. More studies using intakes and biomarkers are needed, however, to determine an association with diverse factors of oxidative damage.

Young Child Nutrition: Knowledge and Surveillance Gaps across the Spectrum of Feeding

The first 1000 days is a critical window to optimize nutrition. Young children, particularly 12–24 month-olds, are an understudied population. Young children have unique nutrient needs and reach important developmental milestones when those needs are met. Intriguingly, there are differences in the dietary patterns and recommendations for young children in the US vs. globally, notably for breastfeeding practices, nutrient and food guidelines, and young child formulas (YCFs)/toddler drinks. This perspective paper compares these differences in young child nutrition and identifies both knowledge gaps and surveillance gaps to be filled. Parental perceptions, feeding challenges, and nutrition challenges are also discussed. Ultimately, collaboration among academia and clinicians, the private sector, and the government will help close young child nutrition gaps in both the US and globally.

The Role of Iodine for Thyroid Function in Lactating Women and Infants

Iodine is a micronutrient needed for the production of thyroid hormones, which regulate metabolism, growth, and development. Iodine deficiency or excess may alter the thyroid hormone synthesis. The potential effects on infant development depend on the degree, timing, and duration of exposure. The iodine requirement is particularly high during infancy because of elevated thyroid hormone turnover. Breastfed infants rely on iodine provided by human milk, but the iodine concentration in breast milk is determined by the maternal iodine intake. Diets in many countries cannot provide sufficient iodine, and deficiency is prevented by iodine fortification of salt. However, the coverage of iodized salt varies between countries. Epidemiological data suggest large differences in the iodine intake in lactating women, infants, and toddlers worldwide, ranging from deficient to excessive intake. In this review, we provide an overview of the current knowledge and recent advances in the understanding of iodine nutrition and its association with thyroid function in lactating women, infants, and toddlers. We discuss risk factors for iodine malnutrition and the impact of targeted intervention strategies on these vulnerable population groups. We highlight the importance of appropriate definitions of optimal iodine nutrition and the need for more data assessing the risk of mild iodine deficiency for thyroid disorders during the first 2 years in life.

Middle East consensus recommendations on the use of young child formula (YCF) in toddlers

The transition of foods during toddlerhood and the suboptimal diets consumed in the Middle East make children susceptible to malnutrition and micronutrient deficiencies. Based on international recommendations, coupled with the merits of clinical studies on the application of young child formula (YCF), a group of fourteen experts from the Middle East reached a consensus on improving the nutritional status of toddlers. The recommendations put forth by the expert panel comprised twelve statements related to the relevance of YCF in young children; the impact of YCF on their nutritional parameters and functional outcomes; characteristics of the currently available YCF and its ideal composition; strategies to supply adequate nutrition in young children and educational needs of parents and healthcare professionals (HCPs). This consensus aims to serve as a guide to HCPs and parents, focusing on improving the nutritional balance in toddlers in the Middle Eastern region. The panellists considere YCF to be one of the potential solutions to improve the nutritional status of young children in the region. Other strategies to improve the nutritional status of young children include fortified cow's milk and cereals, vitamin and mineral supplements, early introduction of meat and fish, and the inclusion of diverse foods in children's diets.

Complementary Feeding and Iron Status: "The Unbearable Lightness of Being" Infants

The complementary feeding (CF) period that takes place between 6 and 24 months of age is of key importance for nutritional and developmental reasons during the transition from exclusively feeding on milk to family meals. In 2021, a multidisciplinary panel of experts from four Italian scientific pediatric societies elaborated a consensus document on CF, focusing in particular on healthy term infants. The aim was to provide healthcare providers with useful guidelines for clinical practice. Complementary feeding is also the time window when iron deficiency (ID) and iron deficiency anemia (IDA) are most prevalent. Thus, it is appropriate to address the problem of iron deficiency through nutritional interventions. Adequate iron intake during the first two years is critical since rapid growth in that period increases iron requirements per kilogram more than at any other developmental stage. Complementary foods should be introduced at around six months of age, taking into account infant iron status.

Latin American Considerations for Infant and Young Child Formulae

Infant formula is the only acceptable substitute for breastmilk from 0 to 6 months old when human milk cannot be provided in sufficient amounts. Manufacturers have developed options that intend to meet the changing needs of the child aged from six to twelve months (follow-on formulae) and after the age of one year (young child formulae). The international code for marketing breast milk substitute stipulates standards for marketing practices of these products. In Latin America there are local variations of marketing practices. Novel marketing strategies such as advertising through social media and influencers pose new threats for breastfeeding success in Latin America. This review aims to examine variations in local regulations for marketing of infant formulae and to analyze the emerging phenomenon of influencer advertising. We reviewed the local norms for Latin American countries and examined differences and possible gaps. Emerging evidence of influencer marketing was explored. The results indicate that national regulations differ among Latin American countries, particularly with respect to product labelling and the requirement to use a local native language, highlighting the cost of the product, and different regulations prohibiting certain messages and illustrations. Regarding new marketing strategies, there is limited evidence on advertising infant formula through social media influencers, where different categories of marketing strategies can be described. More transparent reporting of social marketing by formula providers and more independent research on novel marketing strategies are needed.

Breastfed and Formula-Fed Infants: Need of a Different Complementary Feeding Model?

Suboptimal nutrient quality/quantity during complementary feeding (CF) can impact negatively on infants’ healthy growth, even with adequate energy intake. CF must supplement at best human milk (HM) or formulas, which show nutritional differences. Considering this, a differentiated CF is probably advisable to correctly satisfy the different nutritional needs. To assess whether current needs at 6–24 months of age can still be met by one single CF scheme or different schemes are needed for breastfed vs. formula/cow’s milk (CM) fed infants, protein, iron and calcium intakes were assessed from daily menus using the same type and amount of solid food, leaving same amounts of HM and follow-up formula at 9 and again 18 months of age, when unmodified CM was added. Depending on the child’s age, calcium- and iron-fortified cereals or common retail foods were used. The single feeding scheme keeps protein intake low but higher than recommended, in HM-fed children while in formula/CM-fed ones, it achieves much higher protein intakes. Iron Population Recommended Intake (PRI) and calcium Adequate Intakes (AI) are met at the two ages only when a formula is used; otherwise, calcium-fortified cereals are needed. ESPGHAN statements on the futility of proposing different CF schemes according to the milk type fed do not allow to fully meet the nutritional recommendations issued by major Agencies/Organizations/Societies for all children of these age groups.

Which Milk during the Second Year of Life: A Personalized Choice for a Healthy Future?

Nutrition in early life is a crucial element to provide all essential substrates for growth. Although this statement may appear obvious, several studies have shown how the intake of micro and macronutrients in toddlers differs a lot from the recommendations of scientific societies. Protein intake often exceeds the recommended amount, while the intake of iron and zinc is frequently insufficient, as well as Vitamin D. Nutritional errors in the first years of life can negatively impact the health of the child in the long term. To date, no clear evidence on which milk is suggested during the second year of life is yet to be established. In this study, we compare the nutrient profiles of cow’s milk and specific formulas as well as nutritional risks in toddlers linked to growth and childhood obesity development. The purpose of this review is to resume the latest clinical studies on toddlers fed with cow’s milk or young children formula (YCF), and the potential risks or benefits in the short and long term.

[Nutritional Study in Spanish Pediatric Population (EsNuPI): updated findings and initial conclusions]

INTRODUCTION

eating habits and lifestyles during early childhood are important due to their association with chronic diseases in adulthood.

OBJECTIVES

to evaluate energy and nutrient intake, main food sources, and dietary patterns in the EsNuPI study participants.

METHODS

a sociodemographic questionnaire, food frequency questionnaire, two 24 h recalls, and a physical activity questionnaire were used in two cohorts of Spanish children aged 1 to < 10 years, who were non-vegans living in municipalities > 50,000 inhabitants - one representative cohort of consumers of all types of milks (SRS = 707) and one other cohort consuming adapted milks (AMS = 741).

RESULTS

84.7 % in SRS and 83.5 % in AMS showed a plausible, adequate energy (EI) (1503 and 1404 kcal/day, respectively). The percentage of children with protein intake > 20 % of EI was 12 % for SRS, and 6 % for AMS. Both cohorts exceeded the recommendations for total fat (36.5 % in SRS, 35.9 % in AMS) and saturated fat (13.1 % vs 12.1 %, respectively); DHA intake was significantly lower in SRS (20 mg vs 90 mg). Vitamin D intake was significantly lower in SRS, although both cohorts did not meet the recommendation. When analyzing dietary patterns, one of palatable energy-dense foods and two of Mediterranean type were highlighted.

CONCLUSIONS

it is recommended that consumption of saturated fatty acids and protein be reduced, but calcium, vitamin D, and magnesium intakes should be increased, especially in children > 4 years. These findings are important for designing interventions in the Spanish child population. The findings of the EsNuPI study provide useful information for the design and promotion of appropriate interventions for Spanish children.

A Comparison of the Effects of Young-Child Formulas and Cow's Milk on Nutrient Intakes in Polish Children Aged 13-24 Months

Adequately balanced daily food rations that provide the body with sufficient amounts of energy and nutrients, including minerals, are particularly important in early childhood when rapid physical, intellectual and motor development takes place. Cow’s milk (CM) and young-child formulas (YCFs) are introduced to a child’s diet past the first year of age. The main aim of the present study was to perform a qualitative and a quantitative analysis of daily food rations of young children based on the recommendations of the daily food ration model. An attempt was also made to determine whether the type of consumed milk (YCF or CM) adequately meets young children’s energy demands and contributes to the incorporation of different food groups into a balanced and healthy diet for children aged 13–24 months. A total of 714 parents between October 2019 and March 2020 filled out a food frequency questionnaire. In the second stage of the study, the parents participated in a dietary recall and were asked to keep diaries of all meals and foods consumed by children over a period of three days. The mean daily intake of CM/YCF and fermented milks was determined at 360 mL ± 128 mL, and it accounted for 55.4% of the guideline values. Flavored dairy products were consumed more frequently than fermented milks without added sugar or flavoring (94 ± 17 g vs. 56 ± 26 g, p < 0.05). Diets incorporating CM were significantly more abundant in protein than YCF diets (29.3 g vs. 21.9 g; p < 0.01). Liquid intake was somewhat higher in children fed YCFs (1280.8 mL vs. 1120.1; p < 0.05), mainly due to the higher consumption of fruit juice, nectars and sweetened hot beverages (246 ± 35 mL in the YCF group vs. 201 ± 56 mL in the CM group; p < 0.05). Children fed YCF consumed significantly larger amounts of sweetened beverages such as tea sweetened with sugar or honey, sweetened hot chocolate or instant teas (OR = 2.54; Cl: 1.32–3.26; p < 0.001), than children receiving CM. This group was also characterized by higher consumption of sweetened dairy products, mainly cream cheese desserts, fruit yogurt and yogurt with cereal (OR = 1.87; Cl: 1.36–2.54; p < 0.01), as well as a lower daily intake of plain fermented milks (OR = 0.56; Cl: 0.21–0.79; p < 0.001). The daily food intake and the quality of the diets administered to children aged 13–24 months were evaluated and compared with the model food ration. It was found that milk type influenced children’s eating habits and preference for sweet-tasting foods. The study also demonstrated that Polish parents and caregivers only have limited knowledge of nutritional guidelines for toddlers.

Nutritional Strategies for Childhood Obesity Prevention

BACKGROUND

Reducing the spread of obesity represents a challenge for clinicians in which obesity prevention plays a key role in achieving this purpose. The aim of this review is to analyze the nutritional interventions that can be implemented to prevent childhood obesity.

METHODS

Searching PubMed and Cochrane Library between 2019 and 2021. Further searching with no date range for articles selected for their specific relevance in the pediatric area or for their scientific relevance. A total of 871 articles were identified and 90 were included.

RESULTS

We organized the results of the selected articles into age groups, and according to the subjects targeted for interventions or to the site of interventions, reserving an in-depth analysis on specific nutritional aspects. Promotion of breastfeeding, reduction of protein content of formulated milks, and diet of the first 12-24 months, involving family and schools in interventions that promote physical activity and healthy diet, are promising strategies for reduction of the risk of obesity. To increase the efficacy of interventions, a multidimensional approach is crucial.

CONCLUSIONS

A multidimensional approach, which takes into consideration different areas of intervention, is pivotal for childhood obesity prevention. Integrated programs involving several components (nutrition and physical activity at first) at different levels (individual, family, school, and institutional) are crucial.

Human Milk Concentrations of Minerals, Essential and Toxic Trace Elements and Association with Selective Medical, Social, Demographic and Environmental Factors

This study aims to quantify concentrations of minerals and trace elements in human milk (HM) and infant formula (IF) and evaluate associations with medical, social, environmental, and demographic variables. A prospective, case series study of 170 nursing mothers was made. HM samples were obtained from full-term (colostrum, intermediate and mature HM) and preterm (mature HM) mothers. Variables of interest were assessed by a questionnaire. For comparison, IF samples (n = 30) were analyzed in a cross-sectional study. Concentrations of 35 minerals, essential and toxic trace elements were quantified, 5 for the first time: thallium in HM and IF; strontium in preterm HM; and gallium, lithium and uranium in IF. In preterm and full-term HM, levels of selenium (p < 0.001) were significantly lower than recommended and were associated with low birth weight (p < 0.002). Cesium and strontium concentrations were significantly higher than recommended (p < 0.001). Associations were observed between arsenic and residence in an urban area (p = 0.013), and between lead and smoking (p = 0.024) and well-water consumption (p = 0.046). In IF, aluminum, vanadium, and uranium levels were higher than in HM (p < 0.001); uranium, quantified for the first time, was 100 times higher in all types of IF than in HM. Our results indicate that concentrations of most trace elements were within internationally accepted ranges for HM and IF. However, preterm infants are at increased risk of nutritional deficiencies and toxicity. IF manufacturers should reduce the content of toxic trace elements.

Multi-Nutrient Fortified Dairy-Based Drink Reduces Anaemia without Observed Adverse Effects on Gut Microbiota in Anaemic Malnourished Nigerian Toddlers: A Randomised Dose-Response Study

Prevalence of anaemia among Nigerian toddlers is reported to be high, and may cause significant morbidity, affects brain development and function, and results in weakness and fatigue. Although, iron fortification can reduce anaemia, yet the effect on gut microbiota is unclear. This open-label randomised study in anaemic malnourished Nigerian toddlers aimed to decrease anaemia without affecting pathogenic gut bacteria using a multi-nutrient fortified dairy-based drink. The test product was provided daily in different amounts (200, 400 or 600 mL, supplying 2.24, 4.48 and 6.72 mg of elemental iron, respectively) for 6 months. Haemoglobin, ferritin, and C-reactive protein concentrations were measured to determine anaemia, iron deficiency (ID) and iron deficiency anaemia (IDA) prevalence. Faecal samples were collected to analyse gut microbiota composition. All three dosages reduced anaemia prevalence, to 47%, 27% and 18%, respectively. ID and IDA prevalence was low and did not significantly decrease over time. Regarding gut microbiota, Enterobacteriaceae decreased over time without differences between groups, whereas Bifidobacteriaceae and pathogenic E. coli were not affected. In conclusion, the multi-nutrient fortified dairy-based drink reduced anaemia in a dose-dependent way, without stimulating intestinal potential pathogenic bacteria, and thus appears to be safe and effective in treating anaemia in Nigerian toddlers.

Role of Dietary Factors, Food Habits, and Lifestyle in Childhood Obesity Development: A Position Paper From the European Society for Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition

ABSTRACT

Childhood obesity has high societal and economic impact but current treatment approaches are sub-optimal. In the last decade, important studies have been conducted aiming to identify strategies to prevent obesity during critical periods of life. Updated recommendations for childhood obesity prevention are needed. We present data from systematic reviews and meta- analysis, randomised controlled trials (RCTs) and large observational studies, published from 2011 onwards that consider the possible role of the following factors in obesity development: breast-feeding; macronutrient composition and method of complementary feeding; parenting style; dietary patterns; sugar-sweetened beverage consumption; eating behaviour (eg, skipping breakfast, family dinners. etc); meal frequency and composition (fast foods, snacking), portion size; dietary modulators of gut microbiota (including pre-, pro-, and synbiotics); physical activity and sedentary behaviour. We used the Medline database and the Cochrane Library to search for relevant publications. Important research gaps were also identified. This position paper provides recommendations on dietary factors, food habits, and lifestyle to prevent childhood obesity development, based on the available literature and expert opinion. Clinical research and high-quality trials are urgently needed to resolve numerous areas of uncertainty.

Milk and Dairy Products: Good or Bad for Human Bone? Practical Dietary Recommendations for the Prevention and Management of Osteoporosis

Osteoporosis affects women twice as often as men. Additionally, it is estimated that 0.3 million and 1.7 million people have hip fractures in the USA and Europe, respectively. Having a proper peak bone mass and keeping it as long as possible is especially important for osteoporosis prevention. One of the most important calcium sources is milk and dairy products. Breast milk is the best infant food, but milk should not be avoided later in life to prevent losing bone mass. On the other hand, more and more people limit their milk consumption and consume other dairy or non-dairy products. For example, they are usually replaced with plant beverages, which should be consumed carefully in several age groups. Additionally, an important element of milk and dairy products, as well as plant beverages, are probiotics and prebiotics, which may modulate bone turnover. Dietary recommendations focused on milk, and dairy products are an important element for the prevention of osteoporosis.

What are the new guidelines and position papers in pediatric nutrition: A 2015-2020 overview

BACKGROUND

Nutrition related publications in pediatric population cover wide range of topics and therefore it is usually difficult for clinicians to get an overview of recent nutrition related guidelines or recommendations.

METHODS

The Special Interest Group (SIG) of Pediatrics of European Society for Clinical Nutrition and Metabolism (ESPEN) performed a literature search to capture publications in the last five years aiming to provide the latest information concerning nutritional issues in children in general and in specific diseases and to discuss progression in the field of pediatric nutrition evidence-based practice.

RESULTS

Eight major topics were identified as the most frequently reported including allergy, critical illness, neonatal nutrition, parenteral and enteral nutrition, micronutrients, probiotics and malnutrition. Furthermore, it was noted that many reports were disease focused or included micronutrients and were, therefore, represented as tables.

CONCLUSION

Overall, it has been shown that most reports on nutrition topics in pediatrics were systematic reviews or guidelines/position papers of relevant societies, but many of them basing the conclusion on a limited number of high-quality randomized controlled trials or large observational cohort studies.

Vulnerable families and costly formula: a qualitative exploration of infant formula purchasing among peri-urban Peruvian households

BACKGROUND

Substantial evidence exists surrounding the health risks of breast milk substitutes (BMS) in place of exclusive breastfeeding among infants < 6 months of age in resource-poor settings. Yet, mothers' experiences of selecting and purchasing BMS brands have not been well studied to date. This qualitative study explored the factors influencing BMS purchasing practices, along with the consequences of those decisions, in peri-urban Lima, Peru.

METHODS

We conducted in-depth interviews (IDIs) with 29 mothers who had begun mixed-feeding their infants during the first 6 months of life. Interviews explored participants' reasons for initiating infant formula use and their experiences of selecting, purchasing, and providing BMS to their children. Audio recordings were transcribed, coded, and key themes and illustrative vignettes were identified.

RESULTS

The primary reported reasons for initiating infant formula use included having received a recommendation for infant formula from a healthcare provider, concerns about an infant's weight gain, and the perception of insufficient breast milk. Mothers tended to initially purchase the BMS brand that had been recommended by a doctor, which was often more expensive than the alternatives. The costs of BMS, which escalated as infants grew, often disrupted the household economy and generated significant stress. While some mothers identified alternatives allowing them to continue purchasing the same brand, others chose to switch to less expensive products. Several mothers began to feed their infants follow-on formula or commercial milk, despite their awareness that such practices were not recommended for infants under 6 months of age. The approval of family members and the absence of an infant's immediate adverse reaction influenced mothers' decisions to continue purchasing these products.

CONCLUSIONS

The high costs of BMS may deepen existing socio-economic vulnerabilities and generate new risks for infant health. The continued dedication of resources towards breastfeeding education and support is critical, and strategies would benefit from underscoring the long-term financial and health consequences of infant formula use, and from strengthening women's self-efficacy to refuse to initiate infant formula when recommended. In addition, health providers should be trained in counseling to help women to relactate or return to exclusive breastfeeding after cessation.

Commercial growing up milks: usage frequency and associated child and demographic factors across four Asia Pacific countries

BACKGROUND

Commercial growing up milks (GUMs) targeted at children from 12 to 36 months of age are a rapidly growing industry, particularly across the Asia Pacific.

METHODS

The present study assessed the frequency of use and socio-demographic and child associations of commercial GUM feeding in children, aged between 12 and 36 months, in capital cities in four Asia Pacific countries. Mothers of children aged between 12 and 36 months were surveyed, assessing GUM feeding frequency in the past month. A market research company database was used to survey across Asia Pacific urban cities, including Bangkok Thailand, Jakarta Indonesia, Singapore and Australian Capital Cities (ACC).

RESULTS

More than 1000 women (n = 1051) were surveyed (Bangkok, n = 263; Jakarta, n = 275; ACC, n = 252; Singapore, n = 261). The mean (SD) age of mothers was 32.4 (5.3) years and that of children was 23.6 (6.7) months. In total, 62.7% of the children were fed GUMs more than once per week with significant country variance. In comparison with ACC, Asian countries were significantly more likely to feed GUMs ≥once per week: Bangkok [odds ratio (OR) = 5.7, 95% confidence interval (CI) = 3.8-8.6]; Jakarta (OR = 3.5, 95% CI = 2.3-5.5); and Singapore (OR = 7.4, 95% CI = 4.9-11.1). Associations of GUM feeding included: maternal tertiary education; mothers younger than 30 years; working full time; and feeding of commercial infant formula under 12 months.

CONCLUSIONS

This is the first published study to explore commercial GUM feeding in and between countries. The incidence of GUM feeding, in contrast to international recommendations, signals the need for further research into the drivers for GUM feeding and its contribution to the diet.

Dietary Intake, Nutritional Adequacy and Food Sources of Total Fat and Fatty Acids, and Relationships with Personal and Family Factors in Spanish Children Aged One to <10 Years: Results of the EsNuPI Study

We aimed to determine the usual intake of total fat, fatty acids (FAs), and their main food sources in a representative cohort of the Spanish pediatric population aged 1 to <10 years (n = 707) who consumed all types of milk and an age-matched cohort who consumed adapted milk over the last year (including follow-on formula, toddler's milk, growing-up milk, and fortified and enriched milks) (n = 741) who were participants in the EsNuPI study (in English, Nutritional Study in the Spanish Pediatric Population). Dietary intake, measured through two 24 h dietary recalls, was compared to the European Food Safety Authority (EFSA) and the Food and Agriculture Organization of the United Nations (UN-FAO) recommendations. Both cohorts showed a high intake of saturated fatty acids (SFAs), according to FAO recommendations, as there are no numerical recommendations for SFAs at EFSA. Also, low intake of essential fatty acids (EFAs; linoleic acid (LA) and α-linolenic acid (ALA)) and long-chain polyunsaturated fatty acids (LC-PUFA) of the n-3 series, mainly docosahexaenoic acid (DHA) were observed according to EFSA and FAO recommendations. The three main sources of total fat and different FAs were milk and dairy products, oils and fats, and meat and meat products. The consumption of adapted milk was one of the main factors associated with better adherence to the nutritional recommendations of total fat, SFAs, EFAs, PUFAs; and resulted as the main factor associated with better adherence to n-3 fatty acids intake recommendations. Knowledge of the dietary intake and food sources of total fat and FAs in children could help in designing and promoting effective and practical age-targeted guidelines to promote the consumption of EFA- and n-3 PUFA-rich foods in this stage of life.

Usual Dietary Intake, Nutritional Adequacy and Food Sources of Calcium, Phosphorus, Magnesium and Vitamin D of Spanish Children Aged One to <10 Years. Findings from the EsNuPI Study

Bone problems in the population begin to be establish in childhood. The present study aims to assess the usual calcium, phosphorus, magnesium, and vitamin D intakes, along with the food sources of these nutrients, in Spanish children participating in the EsNuPI (Estudio Nutricional en Población Infantil Española) study. Two 24 h dietary recalls were applied to 1448 children (1 to <10 years) divided into two sub-samples: one reference sample (RS) of the general population [n = 707] and another sample which exclusively included children consuming enriched or fortified milks, here called "adapted milks" (AMS) [n = 741]. Estimation of the usual intake shows that nutrient intake increased with age for all nutrients except vitamin D. Using as reference the Dietary Reference Values from the European Food Safety Authority (EFSA), calcium and magnesium intakes were found to be below the average requirement (AR) and adequate intake (AI), respectively, in a considerable percentage of children. Furthermore, phosphorus exceeded the AI in 100% of individuals and vitamin D was lower than the AI in almost all children studied. The results were very similar when considering only plausible reporters. When analyzing the food sources of the nutrients studied, milk and dairy products contributed the most to calcium, phosphorus, magnesium, and vitamin D. Other sources of calcium were cereals and vegetables; for phosphorus: meat, meat products, and cereals; for magnesium: cereals and fruits; and, for vitamin D: fish and eggs. These results highlight the desirability of improving the intake concerning these nutrients, which are involved in bone and metabolic health in children. The AMS group appeared to contribute better to the adequacy of those nutrients than the RS group, but both still need further improvement. Of special interest are the results of vitamin D intakes, which were significantly higher in the AMS group (although still below the AI), independent of age.

Patterns of the Consumption of Young Children Formula in Chinese Children Aged 1-3 Years and Implications for Nutrient Intake

The consumption of young children formula (YCF) is associated with reduced risk of inadequacies of nutrients that are frequently lacking in the diets of young children. In this study, we assessed the role of YCF in children’s diets and whether meeting dairy intake recommendations would improve nutrient intake in young Chinese children aged 12–36 months. Dietary intake data for children from the 2012 China Maternal and Infant Nutrition and Growth study were analyzed (n = 910). Nutrient intake was compared between YCF consumers and non-consumers, and the theoretical impact of meeting dairy intake recommendations by adding cow’s milk or YCF to children’s diets was assessed using diet modelling. The percent of children consuming YCF was 64.5% and was positively associated with family income and mother’s education level. Compared to non-consumers, YCF consumers had higher intakes of minerals (e.g., calcium, iron) and vitamins (e.g., C, D, B6) that are important for growth and immune function, and lower intakes of saturated fat. To meet dairy intake recommendations by adding either cow’s milk or YCF to children’s diets would improve intakes of vitamins and minerals in young Chinese children. YCF consumption contributes to the improvement of nutrient intakes in children aged 12–36 months in China.

Ortega R, Ruiz-López MD, Varela-Moreiras G, Gil Á. Energy Intake, Macronutrient Profile and Food Sources of Spanish Children Aged One to <10 Years-Results from the EsNuPI Study

The present study aimed to assess energy intake, nutrient profile and food sources in Spanish children participating in the EsNuPI ("Estudio Nutricional en Población Infantil Española") study. Plausibility of energy intake and adequacy of nutrient intakes to international recommendations were analyzed in a final sample of 1448 subjects (728 boys and 720 girls) and one group representative of the 1 to <10 years old urban Spanish children (reference sample (n = 707)) who consumed milk and one of the same age who consumed adapted milk over the last year (adapted milk consumers sample (n = 741)) were compared. Both groups completed data of a face-to-face and a telephone 24-h dietary recalls. Both the reference and the adapted milk consumers samples reported an adequate daily energy intake (1503 kcal/day and 1404 kcal/day); and a high contribution to total energy from protein (16.5% and 15.6%) and fat (36.5% and 35.9%). Also, a high percentage of children from both samples were below the lower limit of the recommendations for carbohydrates (47.8% and 39.3%). As the percentage of plausible energy reporters was high for both groups (84.7% and 83.5%, respectively), data for the whole sample were analyzed. Milk and dairy, cereals, meat and derived products, fats and oils, bakery and pastry, fruits and vegetables contributed to about 80% of the total energy intake in both groups. However, the reference sample reported significantly more contribution to energy from cereals, meat and meat products, bakery and pastry and ready to cook/eat foods; meanwhile, the adapted milk consumers sample reported significantly more energy from milk and dairy products, fruits and eggs. Those results suggest that adapted milk consumers have better adherence to the food-based dietary guidelines. Further analyses are warranted to characterize food patterns and the quality of the diet in the EsNuPI study population.

A comparison of the effect of a Growing Up Milk - Lite (GUMLi) v. cows' milk on longitudinal dietary patterns and nutrient intakes in children aged 12-23 months: the GUMLi randomised controlled trial

The second year of life is a period of nutritional vulnerability. We aimed to investigate the dietary patterns and nutrient intakes from 1 to 2 years of age during the 12-month follow-up period of the Growing Up Milk - Lite (GUMLi) trial. The GUMLi trial was a multi-centre, double-blinded, randomised controlled trial of 160 healthy 1-year-old children in Auckland, New Zealand and Brisbane, Australia. Dietary intakes were collected at baseline, 3, 6, 9 and 12 months post-randomisation, using a validated FFQ. Dietary patterns were identified using principal component analysis of the frequency of food item consumption per d. The effect of the intervention on dietary patterns and intake of eleven nutrients over the duration of the trial were investigated using random effects mixed models. A total of three dietary patterns were identified at baseline: 'junk/snack foods', 'healthy/guideline foods' and 'breast milk/formula'. A significant group difference was observed in 'breast milk/formula' dietary pattern z scores at 12 months post-randomisation, where those in the GUMLi group loaded more positively on this pattern, suggesting more frequent consumption of breast milk. No difference was seen in the other two dietary patterns. Significant intervention effects were seen on nutrient intake between the GUMLi (intervention) and cows' milk (control) groups, with lower protein and vitamin B12, and higher Fe, vitamin D, vitamin C and Zn intake in the GUMLi (intervention) group. The consumption of GUMLi did not affect dietary patterns, however, GUMLi participants had lower protein intake and higher Fe, vitamins D and C and Zn intake at 2 years of age.

Energy and protein requirements for children with CKD stages 2-5 and on dialysis-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce

Dietary management in pediatric chronic kidney disease (CKD) is an area fraught with uncertainties and wide variations in practice. Even in tertiary pediatric nephrology centers, expert dietetic input is often lacking. The Pediatric Renal Nutrition Taskforce (PRNT), an international team of pediatric renal dietitians and pediatric nephrologists, was established to develop clinical practice recommendations (CPRs) to address these challenges and to serve as a resource for nutritional care. We present CPRs for energy and protein requirements for children with CKD stages 2-5 and those on dialysis (CKD2-5D). We address energy requirements in the context of poor growth, obesity, and different levels of physical activity, together with the additional protein needs to compensate for dialysate losses. We describe how to achieve the dietary prescription for energy and protein using breastmilk, formulas, food, and dietary supplements, which can be incorporated into everyday practice. Statements with a low grade of evidence, or based on opinion, must be considered and adapted for the individual patient by the treating physician and dietitian according to their clinical judgment. Research recommendations have been suggested. The CPRs will be regularly audited and updated by the PRNT.

Contribution of Milk Beverages to Nutrient Adequacy of Young Children and Preschool Children in the Philippines

Malnutrition is a major public health concern in the Philippines. Milk and dairy products are important sources of energy, protein, and micronutrients for normal growth and development in children. This study aims to assess the contribution of different types of milk to nutrient intakes and nutrient adequacy among young and preschool children in the Philippines. Filipino children aged one to four years (n = 2992) were analysed while using dietary intake data from the 8th National Nutrition Survey 2013. Children were stratified by age (one to two years and three to four years) and by milk beverage consumption type: young children milk (YCM) and preschool children milk (PCM), other milks (mostly powdered milk with different degrees of fortification of micronutrients), and non-dairy consumers (no milks or dairy products). The mean nutrient intakes and the odds of meeting nutrient adequacy by consumer groups were compared, percentage of children with inadequate intakes were calculated. Half (51%) of Filipino children (all ages) did not consume any dairy on a given day, 15% consumed YCM or PCM, and 34% consumed other milks. Among children one to two years, those who consumed YCM had higher mean intakes of iron, magnesium, potassium, zinc, B vitamins, folate, and vitamins C, D, and E (all p < 0.001) when compared to other milk consumers. Non-dairy consumers had mean intakes of energy, total fat, fibre, calcium, phosphorus, iron, potassium, zinc, folate, and vitamins D and E that were far below the recommendations. Children who consumed YCM or PCM had the highest odds in meeting adequacy of iron, zinc, thiamin, vitamin B6, folate, and vitamins C, D, and E as compared to other milks or non-dairy consumers, after adjusting for covariates. This study supports the hypothesis that dairy consumers had higher intakes of micronutrients and higher nutrient adequacy than children who consumed no milk or dairy products. Secondly, YCM or PCM have demonstrated to be good dairy options to achieve nutrient adequacy in Filipino children.

Early nutrition and gut microbiome: interrelationship between bacterial metabolism, immune system, brain structure, and neurodevelopment

Disturbances of diet during pregnancy and early postnatal life may impact colonization of gut microbiota during early life, which could influence infant health, leading to potential long-lasting consequences later in life. This is a nonsystematic review that explores the recent scientific literature to provide a general perspective of this broad topic. Several studies have shown that gut microbiota composition is related to changes in metabolism, energy balance, and immune system disturbances through interaction between microbiota metabolites and host receptors by the gut-brain axis. Moreover, recent clinical studies suggest that an intestinal dysbiosis in gut microbiota may result in cognitive disorders and behavioral problems. Furthermore, recent research in the field of brain imaging focused on the study of the relationship between gut microbial ecology and large-scale brain networks, which will help to decipher the influence of the microbiome on brain function and potentially will serve to identify multiple mediators of the gut-brain axis. Thus, knowledge about optimal nutrition by modulating gut microbiota-brain axis activity will allow a better understanding of the molecular mechanisms involved in the crosstalk between gut microbiota and the developing brain during critical windows. In addition, this knowledge will open new avenues for developing novel microbiota-modulating based diet interventions during pregnancy and early life to prevent metabolic disorders, as well as neurodevelopmental deficits and brain functional disorders.

The Role of Young Child Formula in Ensuring a Balanced Diet in Young Children (1-3 Years Old)

During the nutritional vulnerable period of 1–3 years of age, nutrient intake is often inadequate due to an unbalanced diet. Young child formula (YCF) has been proposed as a means of improving nutrition in this age group. We compared the food consumption and nutrient intake of 241 YCF consumers (YCF-C) to those of 206 non-consumers (YCF-NC), selected from among the children enrolled in the Nutri-Bébé survey, an observational cross-sectional survey, conducted from 3 January to 21 April 2013. Food consumption and nutrient intake were analyzed from a three-day dietary record. The YCF-C < 2 years group had a protein (−8 g/d; p < 0.0001) and sodium (−18%; p = 0.0003) intake that was lower than that of YCF-NC, but still above the respective EFSA (European Food Safety Authority) Average Requirement (AR) or Adequate Intake (AI). At all ages, the YCF-C group had higher intakes of essential fatty acids (p < 0.0001), vitamins C (p < 0.0001), A, D, and E (p < 0.0001), all B vitamins (p < 0.001) except B12, iron (9 vs. 5 mg/d, p < 0.0001), reaching the Dietary Reference Values (DRVs, AR or AI), but similar DHA and ARA intakes. Getting closer to the reference values proposed by EFSA required at least 360 mL/d of YCF. The consumption of YCF may help infants and children at risk of nutrient deficiencies to meet their nutritional requirements. However, protein, sodium, and vitamin A intakes remained above the EFSA DRVs, and DHA, ARA, and vitamin D remained below.

A Functional Approach to Feeding Difficulties in Children

PURPOSE OF REVIEW

This review provides an approach for resolving a variety of feeding difficulties in children, ranging from normal eating behavior that is misperceived as a problem to substantial feeding disorders.

RECENT FINDINGS

Criteria to identify pediatric feeding disorders have been thoroughly addressed in the newly established designations of avoidant restrictive food intake disorder (ARFID) and pediatric feeding disorder (PFD). These diagnostic criteria improve the accuracy of identifying, classifying, and managing significant feeding disorders in young children. While recent definitions of feeding difficulties are particularly appropriate in multidisciplinary settings, in this paper, we advocate for a progressive approach of managing feeding problems in all clinical settings. It begins by identifying red flags indicative of serious threats to the child, screening for oral motor dysfunction, stabilizing nutrient intake, and eliminating aversive feeding practices. The next step, if eating behavior does not improve, involves strategies that target specific eating behaviors and parental feeding styles. In severe or resistant cases, referral to specialists or interdisciplinary feeding teams is advised.

Iron-fortified formula use in young children and association with socioeconomic factors in the French nationwide ELFE cohort

AIM

To study the rate of iron-fortified infant formula (IFF) use in young children in France and its association with socioeconomic factors.

METHODS

The ELFE national birth cohort included, in 2011, 18 329 living births in 349 hospitals randomly selected. The present analyses were restricted to children with follow-up at age two years. Milk consumption was evaluated by parental telephone interview, and its association with socioeconomic factors was studied.

RESULTS

The 12 341 analysed children had a mean age of 26 months; 50% were girls. Rate of IFF use before two years old and at two years old was 65% and 43%, respectively. At age two years, use of IFF was lower with young age of the mother (adjusted OR [aOR] = 0.4, 95% CI: 0.3-0.5), low educational level (aOR = 0.7, 95% CI: 0.6-0.9), high parity (aOR = 0.3, 95% CI 0.2-0.4), and mother smoking (aOR = 0.8, 95% CI: 0.7-0.9) as well as low household income (aOR = 0.5, 95% CI: 0.4-0.7), and parents' unemployment (aOR = 0.7, 95% CI: 0.5-0.9).

CONCLUSION

In this national population-based study, the rate of implementation of the ID prevention strategy was much lower at two years old than before two years old, and significantly lower in disadvantaged populations.

Evaluation of the Effect of a Growing up Milk Lite vs. Cow's Milk on Diet Quality and Dietary Intakes in Early Childhood: The Growing up Milk Lite (GUMLi) Randomised Controlled Trial

scores provide an alternative approach to measuring dietary quality. The Growing Up Milk-Lite (GUMLi) Trial was a multi-centre, double-blinded, randomised controlled trial of children randomised to receive a reduced protein GUM (GUMLi) or unfortified cow's milk (CM). In a secondary analysis of the GUMLi Trial, we used the Probability of Adequate Nutrient Intake (PANDiet) to determine the nutritional adequacy of the diets of participating children living in Auckland. The PANDiet was adapted to the New Zealand Nutrient Reference Values and data from four 24 h Recalls (24HR) collected at months 7, 8, 10, and 11 post-randomisation were used. Differences between randomised groups (GUMLi vs. CM) of the PANDiet and its components were made. Eighty-three Auckland participants were included in the study (GUMLi n = 41 vs. CM n = 42). Total PANDiet scores were significantly higher in the GUMLi group (p < 0.001), indicating better overall nutrient adequacy and diet quality. Dietary intakes of children in both groups met the recommendations for fat, total carbohydrates and most micronutrients; however, protein intakes exceeded recommendations. Consumption of GUMLi was associated with higher nutritional adequacy, with an increased likelihood of meeting nutrient requirements; however, the impact of the family diet and GUMLi on dietary diversity requires further evaluation.

Compared with Cow Milk, a Growing-Up Milk Increases Vitamin D and Iron Status in Healthy Children at 2 Years of Age: The Growing-Up Milk-Lite (GUMLi) Randomized Controlled Trial

Background

Iron deficiency (ID) and vitamin D deficiency (VDD) are significant pediatric health issues in New Zealand and Australia and remain prevalent micronutrient deficiencies in young children globally.

Objective

We aimed to investigate the effect of a micronutrient-fortified, reduced-energy growing-up milk (GUMLi) compared with cow milk (CM) consumed for 1 y on dietary iron and vitamin D intakes and the status of New Zealand and Australian children at 2 y of age.

Methods

The GUMLi Trial was a multicenter, double-blind, randomized controlled trial in 160 healthy 1-y-old New Zealand and Australian children conducted in 2015-2017. Participants were randomly assigned 1:1 to receive GUMLi (1.7 mg Fe/100 mL; 1.3 µg cholecalciferol/100 mL) or CM (0.02 mg Fe/100 mL; 0.06 µg cholecalciferol/100 mL) for 12 mo. Secondary outcomes, reported here, included change in dietary iron and vitamin D intakes, iron status, and 25-hydroxyvitamin D [25(OH)D] concentrations from blood samples at age 2 y. All regression models were adjusted for baseline outcome and study center.

Results

GUMLi was a large contributor to dietary intakes of iron and vitamin D after 12 mo when compared with intakes from food and CM. The adjusted mean difference between groups for serum ferritin concentrations was 17.8 µg/L (95% CI: 13.6, 22.0 µg/L; P < 0.0001), and for 25(OH)D it was 16.6 nmol/L (95% CI: 9.9, 23.3 nmol/L; P < 0.0001). After 12 mo, ID was present in 16 (24%) participants in the CM group and 5 (7%) participants in the GUMLi group (P = 0.009), and the prevalence of VDD in the CM group increased to 14% (n = 10) and decreased to 3% (n = 2) (P = 0.03) in the GUMLi group.

Conclusion

In comparison with CM, GUMLi significantly improved dietary iron and vitamin D intakes and the iron and vitamin D status of healthy children at 2 y of age. This trial was registered with the Australian New Zealand Clinical Trials Registry (www.anzctr.org.au) as ACTRN12614000918628.

Cow's Milk Consumption and Health: A Health Professional's Guide

The most recent scientific evidence supports the consumption of cow's milk and dairy products as part of a balanced diet. However, these days, the public and practicing physicans are exposed to a stream of inconsistent (and often misleading) information regarding the relationship between cow's milk intake and health in the lay press and in the media. The purpose of this article, in this context, is to facilitate doctor-patient communication on this topic, providing physicians with a series of structured answers to frequently asked patient questions. The answers range from milk and milk-derived products' nutritional function across the life span, to their relationship with diseases such as osteoporosis and cancer, to lactose intolerance and milk allergy, and have been prepared by a panel of experts from the Italian medical and nutritional scientific community. When consumed according to appropriate national guidelines, milk and its derivatives contribute essential micro- and macronutrients to the diet, especially in infancy and childhood where bone mass growth is in a critical phase. Furthermore, preliminary evidence suggests potentially protective effects of milk against overweight, obesity, diabetes, and cardiovascular disease, while no clear data suggest a significant association between milk intake and cancer. Overall, current scientific literature suggests that an appropriate consumption of milk and its derivatives, according to available nutritional guidelines, may be beneficial across all age groups, with the exception of specific medical conditions such as lactose intolerance or milk protein allergy. Key teaching points: Milk and its derivatives contribute essential micro and macronutrients to the diet, when consumed according to appropriate national guidelines, especially in infancy and childhood where bone mass growth is in a critical phase. Preliminary evidence suggests potentially protective effects of milk against overweight, obesity, diabetes and cardiovascular disease No clear data are available about the association between milk intake and cancer. Current scientific literature suggests that an appropriate consumption of milk and its derivatives may be beneficial at all ages, with the exception of specific medical conditions such as lactose intolerance or milk protein allergy.