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van Veen LEJ, van der Weijden BM, Achten NB, van der Lee L, Hol J, van Rossem MC, Rijpert M, Oorthuys AOJ, van Beek RHT, Dubbink-Verheij GH, Kornelisse RF, van der Meer-Kapelle LH, Van Mechelen K, Broekhuizen S, Dassel ACM, Jacobs JWFMC, van Rijssel PWT, Tramper-Stranders GA, van Rossum AMC, Plötz FB. Incidence of Antibiotic Exposure for Suspected and Proven Neonatal Early-Onset Sepsis between 2019 and 2021: A Retrospective, Multicentre Study. Antibiotics (Basel) 2024; 13:537. [PMID: 38927203 PMCID: PMC11200437 DOI: 10.3390/antibiotics13060537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 06/03/2024] [Accepted: 06/06/2024] [Indexed: 06/28/2024] Open
Abstract
Management of suspected early-onset sepsis (EOS) is undergoing continuous evolution aiming to limit antibiotic overtreatment, yet current data on the level of overtreatment are only available for a select number of countries. This study aimed to determine antibiotic initiation and continuation rates for suspected EOS, along with the incidence of culture-proven EOS in The Netherlands. In this retrospective study from 2019 to 2021, data were collected from 15 Dutch hospitals, comprising 13 regional hospitals equipped with Level I-II facilities and 2 academic hospitals equipped with Level IV facilities. Data included birth rates, number of neonates started on antibiotics for suspected EOS, number of neonates that continued treatment beyond 48 h and number of neonates with culture-proven EOS. Additionally, blood culture results were documented. Data were analysed both collectively and separately for regional and academic hospitals. A total of 103,492 live-born neonates were included. In 4755 neonates (4.6%, 95% CI 4.5-4.7), antibiotic therapy was started for suspected EOS, and in 2399 neonates (2.3%, 95% CI 2.2-2.4), antibiotic treatment was continued beyond 48 h. Incidence of culture-proven EOS was 1.1 cases per 1000 live births (0.11%, 95% CI 0.09-0.14). Overall, for each culture-proven EOS case, 40.6 neonates were started on antibiotics and in 21.7 neonates therapy was continued. Large variations in treatment rates were observed across all hospitals, with the number of neonates initiated and continued on antibiotics per culture-proven EOS case varying from 4 to 90 and from 4 to 56, respectively. The high number of antibiotic prescriptions compared to the EOS incidence and wide variety in clinical practice among hospitals in The Netherlands underscore both the need and potential for a novel approach to the management of neonates with suspected EOS.
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Affiliation(s)
- Liesanne E. J. van Veen
- Department of Paediatrics, Franciscus Gasthuis en Vlietland, Kleiweg 500, 3045 PM Rotterdam, The Netherlands
- Department of Paediatrics, Erasmus MC University Medical Center, Sophia Children’s Hospital, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
- Department of Paediatrics, Tergooi MC, Laan van Tergooi 2, 1212 VG Hilversum, The Netherlands
| | - Bo M. van der Weijden
- Department of Paediatrics, Tergooi MC, Laan van Tergooi 2, 1212 VG Hilversum, The Netherlands
- Department of Paediatrics, Amsterdam UMC, Emma Children’s Hospital, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Niek B. Achten
- Department of Paediatrics, Erasmus MC University Medical Center, Sophia Children’s Hospital, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - Lotte van der Lee
- Department of Paediatrics, Amsterdam UMC, Emma Children’s Hospital, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Jeroen Hol
- Department of Paediatrics, Noordwest Hospital, Wilhelminalaan 12, 1815 JD Alkmaar, The Netherlands
| | - Maaike C. van Rossem
- Department of Paediatrics, Rijnstate Hospital, Wagnerlaan 55, 6815 AD Arnhem, The Netherlands
| | - Maarten Rijpert
- Department of Paediatrics, Zaans Medical Centre, Kon. Julianaplein 58, 1502 DV Zaandam, The Netherlands
| | - Anna O. J. Oorthuys
- Department of Paediatrics, Amsterdam UMC, Emma Children’s Hospital, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Department of Paediatrics, Dijklander Hospital, Maelsonstraat 3, 1624 NP Hoorn, The Netherlands
| | - Ron H. T. van Beek
- Department of Paediatrics, Amphia Hospital, Molengracht 21, 4818 CK Breda, The Netherlands
| | | | - René F. Kornelisse
- Department of Neonatal and Paediatric Intensive Care, Division of Neonatology, Erasmus MC University Medical Center, Sophia Children’s Hospital, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | | | - Karen Van Mechelen
- Department of Neonatology, Maastricht University Medical Center (MUMC+), MosaKids Children’s Hospital, 6229 HX Maastricht, The Netherlands
| | - Suzanne Broekhuizen
- Department of Paediatrics, Wilhelmina Hospital Assen, Europaweg-Zuid 1, 9400 RA Assen, The Netherlands
| | - A. Carin M. Dassel
- Department of Paediatrics, Deventer Hospital, Nico Bolkesteinlaan 75, 7416 SE Deventer, The Netherlands
| | - J. W. F. M. Corrie Jacobs
- Department of Paediatrics, Jeroen Bosch Hospital, Henri Dunantstraat 1, 5223 GZ Hertogenbosch, The Netherlands
| | - Paul W. T. van Rijssel
- Department of Paediatrics, Maaziekenhuis Pantein, Dokter Kopstraat 1, 5835 DV Beugen, The Netherlands
| | - Gerdien A. Tramper-Stranders
- Department of Paediatrics, Franciscus Gasthuis en Vlietland, Kleiweg 500, 3045 PM Rotterdam, The Netherlands
- Department of Paediatrics, Erasmus MC University Medical Center, Sophia Children’s Hospital, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - Annemarie M. C. van Rossum
- Department of Paediatrics, Erasmus MC University Medical Center, Sophia Children’s Hospital, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - Frans B. Plötz
- Department of Paediatrics, Tergooi MC, Laan van Tergooi 2, 1212 VG Hilversum, The Netherlands
- Department of Paediatrics, Amsterdam UMC, Emma Children’s Hospital, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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The association between exposure to antibiotics in the first week of life and later otitis media: The INCA study. Int J Pediatr Otorhinolaryngol 2023; 164:111415. [PMID: 36521193 DOI: 10.1016/j.ijporl.2022.111415] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/20/2022] [Accepted: 12/08/2022] [Indexed: 12/13/2022]
Abstract
UNLABELLED Otitis media (OM) is one of the most common diagnoses in preschool-age children. Its pathophysiology is poorly understood, but is associated with changes in the nasopharyngeal microbiome, immune system, and presence of allergies. These, in turn, can be affected by early-life antibiotic exposure. Therefore, this study aimed to determine if antibiotic treatment in the first week of life in children born at term was associated with acute otitis media (AOM) and otitis media with effusion (OME) in the first 4-6 years of life. METHODS A prospective birth cohort of 436 term-born infants was followed up at 4-6 years of age. Parents reported (recurrent) AOM and OME through online questionnaires, sent to parents of 418 eligible children. Doctors' diagnoses of AOM and OME were collected after additional informed consent. Multivariate logistic regression analyses were used to study the association between antibiotic exposure and AOM and OME. RESULTS Of the 436 infants, 151 infants received antibiotics in the first week of life. In total, 341 (82%) questionnaires were collected. The parental-reported prevalence was 45% (155/341) for AOM. Of these 155 children, 33 children also had OME (10% of the total cohort). Doctor's diagnoses were obtained from 308 (74%) children, of which 30% (91/308) had AOM. Of these 91 children, 12 children also had OME and 8 children had OME without a diagnosis of AOM (6% of the total obtained diagnoses). Antibiotic treatment in the first week of life was not significantly associated with parent-reported nor doctor-diagnosed (recurrent) AOM and OME in the first 4-6 years of life in the regression models. CONCLUSION Antibiotic treatment in the first week of life was not associated with AOM and OME in the first 4-6 years of life in this prospective cohort of Dutch infants. More insight into the pathophysiology of OM is warranted to determine whether antibiotic-induced microbiome changes play a role in the susceptibility to OM.
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Kamphorst K, Rincon AL, Vlieger AM, Garssen J, van ’t Riet E, van Elburg RM. Predictive factors for allergy at 4-6 years of age based on machine learning: a pilot study. PHARMANUTRITION 2022. [DOI: 10.1016/j.phanu.2022.100326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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How primary care providers can help prevent food allergies. Curr Opin Pediatr 2022; 34:430-437. [PMID: 35797492 DOI: 10.1097/mop.0000000000001145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW IgE-mediated food allergy rates have increased in recent decades, yet treatment options remain limited. Prevention strategies are thus essential. We will review recent research and consensus guidelines for food allergy prevention. RECENT FINDINGS Research has continued to support that early introduction of allergens via the gastrointestinal tract induces tolerance and prevents development of food allergy. In contrast, allergen sensitization may occur via transcutaneous allergen exposure. This is supported by research that shows a decreased risk of food allergy with aggressive treatment of atopic dermatitis. More recent research suggests that transcutaneous sensitization could also be facilitated by frequent emollient use in the absence of atopic dermatitis but definitive research is lacking. Murine models have shown a likely role of dysbiosis, or disruption of the body's normal healthy microbiome, in development of food allergy, yet human studies have yet to show a conclusive benefit of probiotics in the prevention of food allergy. SUMMARY Important approaches for food allergy prevention are: introduction of peanut and cooked egg at 4-6 months, early introduction of other allergenic foods, and early diagnosis and treatment of atopic dermatitis (because of a predisposition to food sensitization through the damaged skin barrier). More research is needed to clarify the role, if any, of emollient use and probiotics.
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Abstract
OBJECTIVES Antibiotics may contribute to the development of functional gastrointestinal disorders (FGIDs). This study aimed to determine whether antibiotics during the first week of life, infantile colic in the first year of life, gut-associated immune markers at 1 year of age, and allergies at 4-6 years of age in term-born children were associated with a higher prevalence of FGIDs at 4-6 years of age. METHODS A prospective observational cohort of 436 term-born infants was followed up at the age of 4-6 years; 151 received broad-spectrum antibiotics (AB+), and 285 healthy controls (AB-). Validated Questionnaire On Pediatric Gastrointestinal Symptoms-Rome III and International Study of Asthma and Allergy in Childhood questionnaires were sent to parents of 418 available children. The independent t-test, chi-squared test or non-parametric test and logistic multivariate regression analyses were used. RESULTS In total, 340 of 418 (81%) questionnaires were completed. Only the presence of functional abdominal pain was significantly higher in AB+ than AB- (4% vs 0.4%, respectively, P = 0.045). Children with food allergy fulfilled significantly more often the criteria for irritable bowel syndrome (IBS) and abdominal migraine (26% vs 9%, P = 0.002 and 7% vs 1%, P = 0.043, respectively) compared to non-allergic children. No differences in FGIDs existed at the age of 4-6 years between children with and without a history of infantile colic. There were significant differences in gut-associated immune markers between children with and without FGIDs. CONCLUSION Antibiotics during the first week of life resulted in a higher risk for functional abdominal pain at 4-6 years. Furthermore, food allergy was associated with IBS and abdominal migraine at 4-6years.
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Van Daele E, Kamphorst K, Vlieger AM, Hermes G, Milani C, Ventura M, Belzer C, Smidt H, van Elburg RM, Knol J. Effect of antibiotics in the first week of life on faecal microbiota development. Arch Dis Child Fetal Neonatal Ed 2022; 107:fetalneonatal-2021-322861. [PMID: 35534183 PMCID: PMC9606546 DOI: 10.1136/archdischild-2021-322861] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 03/17/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Infants are frequently exposed to antibiotics (AB) in the first week of life for suspected bacterial infections. Little is known about the effect of AB on the developing intestinal microbiota. Therefore, we studied intestinal microbiota development with and without AB exposure in the first week of life in term born infants. METHODS We analysed the faecal microbiota from birth until 2.5 years of age by 16S rRNA gene amplicon sequencing in a cohort with 56 term born infants, exposed to AB in the first week of life (AB+) (AB for 2-3 days (AB2, n=20), AB for 7 days (AB7, n=36)), compared with 126 healthy controls (AB-). The effects of AB and duration were examined in relation to delivery and feeding mode. RESULTS AB+ was associated with significantly increased relative abundance of Enterobacteriaceae at 3 weeks and 1 year and a decrease of Bifidobacteriaceae, from 1 week until 3 months of age only in vaginally delivered, but not in C-section born infants. Similar deviations were noted in AB7, but not in AB2. After AB, breastfed infants had lower relative abundance of potentially pathogenic Enterobacteriaceae compared with formula fed infants and recovered 2 weeks faster towards controls. CONCLUSIONS AB exposure in the first week of life alters faecal microbiota development with deviations in the relative abundance of individual taxa until 1 year of age. These alterations can have long-term health consequences, which emphasises the need for future studies aiming at restoring intestinal microbiota after AB administration.
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Affiliation(s)
- Emmy Van Daele
- Laboratory of Microbiology, Wageningen University & Research, Wageningen, The Netherlands
| | - Kim Kamphorst
- Pediatrics, Amsterdam Gastroenterology, Metabolism & Nutrition, Amsterdam Reproduction & Development, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
- Pediatrics, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Arine M Vlieger
- Pediatrics, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Gerben Hermes
- Laboratory of Microbiology, Wageningen University & Research, Wageningen, The Netherlands
| | - Christian Milani
- Laboratory of Probiogenomics, Department of Chemistry, Life Sciences and Environmental Sustainability, University of Parma Department of Chemical Life Sciences and Environmental Sustainability, Parma, Emilia-Romagna, Italy
- Interdepartmental Research Centre "Microbiome Research Hub", University of Parma, Parma, Emilia-Romagna, Italy
| | - Marco Ventura
- Laboratory of Probiogenomics, Department of Chemistry, Life Sciences and Environmental Sustainability, University of Parma Department of Chemical Life Sciences and Environmental Sustainability, Parma, Emilia-Romagna, Italy
- Interdepartmental Research Centre "Microbiome Research Hub", University of Parma, Parma, Emilia-Romagna, Italy
| | - Clara Belzer
- Laboratory of Microbiology, Wageningen University & Research, Wageningen, The Netherlands
| | - Hauke Smidt
- Laboratory of Microbiology, Wageningen University & Research, Wageningen, The Netherlands
| | - Ruurd M van Elburg
- Pediatrics, Amsterdam Gastroenterology, Metabolism & Nutrition, Amsterdam Reproduction & Development Amsterdam, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Jan Knol
- Laboratory of Microbiology, Wageningen University & Research, Wageningen, The Netherlands
- Nutricia Research BV, Utrecht, The Netherlands
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Kamphorst K, Carpay NC, de Meij TGJ, Daams JG, van Elburg RM, Vlieger AM. Clinical outcomes following pre-, pro- and synbiotic supplementation after caesarean birth or antibiotic exposure in the first week of life in term born infants: A systematic review of the literature. Front Pediatr 2022; 10:974608. [PMID: 36299694 PMCID: PMC9589227 DOI: 10.3389/fped.2022.974608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 09/16/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Caesarean section and early exposure to antibiotics disrupt the developing gastrointestinal microbiome, which is associated with long-term health effects. OBJECTIVE The aim of this systematic review was to summarise the impact of prebiotics, probiotics, or synbiotics supplementation on clinical health outcomes of term infants born by caesarean section or exposed to antibiotics in the first week of life. DESIGN A systematic search was performed in Medline and Embase from inception to August 2021. Title and abstract screening (n = 11,248), full text screening (n = 48), and quality assessment were performed independently by two researchers. RESULTS Six RCTs studying caesarean born infants were included, group sizes varied between 32-193 with in total 752 children. No studies regarding supplementation after neonatal antibiotic exposure were found. Three studies administered a probiotic, one a prebiotic, one a synbiotic, and one study investigated a prebiotic and synbiotic. Several significant effects were reported at follow-up varying between 10 days and 13 years: a decrease in atopic diseases (n = 2 studies), higher immune response to tetanus and polio vaccinations (n = 2), lower response to influenza vaccination (n = 1), fewer infectious diseases (n = 2), and less infantile colic (n = 1), although results were inconsistent. CONCLUSIONS Supplementation of caesarean-born infants with prebiotics, probiotics, or synbiotics resulted in significant improvements in some health outcomes as well as vaccination responses. Due to the variety of studied products and the paucity of studies, no recommendations can be given yet on the routine application of prebiotics, probiotics, or synbiotics to improve health outcomes after caesarean section or neonatal antibiotic exposure.
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Affiliation(s)
- Kim Kamphorst
- Department of Pediatrics, Amsterdam UMC, Location University of Amsterdam, Amsterdam Gastroenterology and Metabolism Research Institute, Amsterdam, Netherlands.,Department of Pediatrics, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Nora C Carpay
- Department of Pediatrics, Amsterdam UMC, Location University of Amsterdam, Amsterdam Gastroenterology and Metabolism Research Institute, Amsterdam, Netherlands
| | - Tim G J de Meij
- Department of Pediatric Gastroenterology, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Joost G Daams
- Medical Library, Amsterdam UMC, Location University of Amsterdam, Amsterdam, Netherlands
| | - Ruurd M van Elburg
- Department of Pediatrics, Amsterdam UMC, Location University of Amsterdam, Amsterdam Gastroenterology and Metabolism Research Institute, Amsterdam, Netherlands
| | - Arine M Vlieger
- Department of Pediatrics, St. Antonius Hospital, Nieuwegein, Netherlands
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Garcia TM, van Roest M, Vermeulen JLM, Meisner S, Smit WL, Silva J, Koelink PJ, Koster J, Faller WJ, Wildenberg ME, van Elburg RM, Muncan V, Renes IB. Early Life Antibiotics Influence In Vivo and In Vitro Mouse Intestinal Epithelium Maturation and Functioning. Cell Mol Gastroenterol Hepatol 2021; 12:943-981. [PMID: 34102314 PMCID: PMC8346670 DOI: 10.1016/j.jcmgh.2021.05.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS The use of antibiotics (ABs) is a common practice during the first months of life. ABs can perturb the intestinal microbiota, indirectly influencing the intestinal epithelial cells (IECs), but can also directly affect IECs independent of the microbiota. Previous studies have focused mostly on the impact of AB treatment during adulthood. However, the difference between the adult and neonatal intestine warrants careful investigation of AB effects in early life. METHODS Neonatal mice were treated with a combination of amoxicillin, vancomycin, and metronidazole from postnatal day 10 to 20. Intestinal permeability and whole-intestine gene and protein expression were analyzed. IECs were sorted by a fluorescence-activated cell sorter and their genome-wide gene expression was analyzed. Mouse fetal intestinal organoids were treated with the same AB combination and their gene and protein expression and metabolic capacity were determined. RESULTS We found that in vivo treatment of neonatal mice led to decreased intestinal permeability and a reduced number of specialized vacuolated cells, characteristic of the neonatal period and necessary for absorption of milk macromolecules. In addition, the expression of genes typically present in the neonatal intestinal epithelium was lower, whereas the adult gene expression signature was higher. Moreover, we found altered epithelial defense and transepithelial-sensing capacity. In vitro treatment of intestinal fetal organoids with AB showed that part of the consequences observed in vivo is a result of the direct action of the ABs on IECs. Lastly, ABs reduced the metabolic capacity of intestinal fetal organoids. CONCLUSIONS Our results show that early life AB treatment induces direct and indirect effects on IECs, influencing their maturation and functioning.
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Affiliation(s)
- Tânia Martins Garcia
- Department of Gastroenterology and Hepatology, Tytgat Institute for Intestinal and Liver Research, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - Manon van Roest
- Department of Gastroenterology and Hepatology, Tytgat Institute for Intestinal and Liver Research, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - Jacqueline L M Vermeulen
- Department of Gastroenterology and Hepatology, Tytgat Institute for Intestinal and Liver Research, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - Sander Meisner
- Department of Gastroenterology and Hepatology, Tytgat Institute for Intestinal and Liver Research, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - Wouter L Smit
- Department of Gastroenterology and Hepatology, Tytgat Institute for Intestinal and Liver Research, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands; Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Joana Silva
- Department of Oncogenomics, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Pim J Koelink
- Department of Gastroenterology and Hepatology, Tytgat Institute for Intestinal and Liver Research, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - Jan Koster
- Department of Oncogenomics, Amsterdam, the Netherlands
| | - William J Faller
- Department of Oncogenomics, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Manon E Wildenberg
- Department of Gastroenterology and Hepatology, Tytgat Institute for Intestinal and Liver Research, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - Ruurd M van Elburg
- Department of Pediatrics, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Vanesa Muncan
- Department of Gastroenterology and Hepatology, Tytgat Institute for Intestinal and Liver Research, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands.
| | - Ingrid B Renes
- Department of Pediatrics, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Danone Nutricia Research, Utrecht, the Netherlands
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