Adherence to Mediterranean Diet of Breastfeeding Mothers and Fatty Acids Composition of Their Human Milk: Results From the Italian MEDIDIET Study

Background and Aims

The content of fatty acids (FA) in human milk may be influenced by maternal nutrition. We evaluated the role of a Mediterranean diet in influencing the content of FA in human milk among 282 breastfeeding mothers participating in the MEDIDIET study.

Materials and Methods

Mediterranean Diet Score (MDS), a composite index, was used to evaluate adherence to the Mediterranean diet. It includes 9 components (i.e., vegetables, fruit, cereals, legumes, monounsaturated to saturated FA ratio – MUFA/SFA, fish, dairy products, meat, and alcohol) and therefore potentially ranges from 0 (no adherence) to 9 (complete adherence) points. None of the mothers obtained the highest score due to the low alcohol consumption in the study population. Mothers were categorized in approximate tertiles of adherence: 0–3 (34.4%), 4 (26.2%), and 5–8 points (39.4%). The mean content of FA across categories of MDS was compared using ANOVA and test for trend.

Results

A high adherence of breastfeeding mothers to the Mediterranean diet was associated with lower content of SFA in human milk (42.58 ± 4.36 for MDS = 0–3, 42.58 ± 4.89 for MDS = 4, and 40.92 ± 5.22% of fats for MDS = 5–8 points; p ANOVA and p for trend = 0.02). Conversely, a high adherence was associated with higher content of MUFA in human milk (43.27 ± 4.27 for MDS = 0–3, 43.27 ± 4.47 for MDS = 4, and 45.24 ± 5.22% of fats for MDS = 5–8 points; p ANOVA and p for trend < 0.01), ω-3 FA (1.07 ± 0.25 for MDS = 0–3, 1.22 ± 0.49 for MDS = 4, and 1.31 ± 0.51% of fats for MDS = 5–8 points; p ANOVA and p for trend < 0.01), and the major types of ω-3 FA (i.e., α-linolenic acid – ALA, eicosapentaenoic acid – EPA, docosahexaenoic acid – DHA, docosapentaenoic acid – DPA). These associations were mainly driven by the adherence to the vegetables, MUFA/SFA, fish, and dairy products components of the Mediterranean diet.

Conclusion

A high adherence to the Mediterranean diet was associated with human milk showing a lower content of SFA and higher content of MUFA and ω-3 FA, including DHA. The Mediterranean diet may contribute in human milk production with higher content of specific FA which is directly involved in infant’s neural and visual development, as reported by previous studies.

Dietary Intake of Breastfeeding Mothers in Developed Countries: A Systematic Review and Results of the MEDIDIET Study

BACKGROUND

Lactation is a demanding period for women, and a good nutrition is crucial for optimal health of mothers and infants.

OBJECTIVES

To provide new data and summarize the overall evidence on maternal nutrient intakes during lactation in developed countries, we present a systematic review (SR) of the literature and concurrently original results of the Italian MEDIDIET study. We compared nutrient intakes with dietary reference values (DRVs) proposed by the European Food Safety Authority.

METHODS

Studies were identified searching PubMed/Embase databases up to February 2020. Observational studies reporting at least energy and macronutrient intakes of healthy breastfeeding mothers who followed non-restricted and non-specific diets were included. Studies on populations with severe nutritional deficiencies were excluded. The MEDIDIET study enrolled 300 healthy breastfeeding mothers at 6 ± 1 wk postpartum. Usual diet was concomitantly evaluated through a validated and reproducible FFQ. Nutrient intakes were estimated using a food composition database.

RESULTS

Twenty-eight articles regarding 32 distinct study populations were included. Maternal nutrient intakes were generally in agreement across studies included in the SR and conforming to DRVs. Within micronutrients, vitamin D intake was below the recommendation. In the MEDIDIET study, mean intakes of energy (1950 ± 445 kcal/d), carbohydrates (270 ± 20.1 g/d), proteins (87.8 ± 20.1 g/d), and fats (65.6 ± 18.9 g/d) were similar to those observed in the SR. Moreover, observed intakes seemed to reflect the typical Mediterranean diet, with low intakes of carbohydrates, SFAs, and PUFAs and high intakes of MUFAs and vitamins. Conversely, protein intake was mainly derived from animal sources.

CONCLUSIONS

This SR showed that nutrient intakes of breastfeeding mothers in developed countries are generally in line with DRVs despite different dietary patterns worldwide. Some nutritional deficiencies emerged, highlighting the need for additional nutritional advice. Mothers participating in the MEDIDIET study showed a nutritional profile in agreement with the Mediterranean diet.

IgA antiendomysial antibodies on the umbilical cord in diagnosing celiac disease. Sensitivity, specificity, and comparative evaluation with the traditional kit

BACKGROUND

The possibility of assaying antiendomysial antibodies (EmA) on the human umbilical cord instead of monkey esophagus has recently been suggested. We therefore evaluated in patients with celiac disease (CD) the sensitivity and specificity of EmA and of antigliadin antibodies (AGA) for both umbilical cord and monkey esophagus.

METHODS

We studied 36 patients with CD and atrophy of the intestinal mucosa (median age, 1.4 years), 14 patients with CD on gluten-free diet for 8-12 months (median age, 3.0 years), 36 controls without gastrointestinal disease (median age, 4.0 years), and 72 patients with cow's milk protein enteropathy (CMPE) (median age, 1.2 years). AGA and EmA on monkey esophagus were assayed with commercially available kits; the slides with umbilical cord were prepared in our laboratory.

RESULTS

There was a perfect concordance between EmA results evaluated on umbilical cord and those on monkey esophagus; there was a doubtful result in only one case on human umbilical cord, which was positive with low titer on monkey esophagus. EmA specificity was 100%; the specificity of AGA IgG varied between 72% and 94% and of AGA IgA between 90% and 100% depending on whether controls without gastrointestinal disorders or patients with CMPE were considered. EmA sensitivity was 97%, AGA IgG was 89%, and AGA IgA 72% sensitive. The only false negative for EmA was positive for AGA IgG and AGA IgA.

CONCLUSIONS

Using human umbilical cord as a substrate for EmA may provide the same sensitivity and specificity as offered by the test using monkey esophagus substrate, thus reducing costs and avoiding the use of endangered species.

Gastroesophageal reflux and cow's milk allergy in infants: a prospective study

BACKGROUND

Recent reports have suggested that gastroesophageal reflux in pediatric patients may be caused by food allergy.

OBJECTIVE

The aim of our study was to determine the frequency of the association of gastroesophageal reflux with cow's milk protein allergy in patients win the first year of life.

METHODS

We studied 204 consecutive patients (median age, 6.3 months) who had been diagnosed as having gastroesophageal reflux on the basis of 24-hour continuous pH monitoring and histologic examination of the esophageal mucosa.

RESULTS

Clinical history suggested diagnosis of cow's milk allergy in 19 infants, and 93 others had positive test results (serum IgE anti-lactoglobulin, prick tests, circulating or fecal or nasal mucus eosinophils) but did not have symptoms indicating cow's milk allergy. The cow's milk-free diet and two successive blind challenges confirmed the diagnosis of cow's milk allergy in 85 of the 204 patients with gastroesophageal reflux. The clinical presentations of the infants with gastroesophageal reflux alone were different, in view of the greater frequency of diarrhea (p less than 0.0001) and atopic dermatitis (p less than 0.0002). In all, gastroesophageal reflux was associated with, and probably caused by cow's milk allergy, in 85 of 204 cases (41.8%).

CONCLUSIONS

Considering the frequency of this association, patients younger than 12 months old with symptoms of gastroesophageal reflux should be carefully examined to determine whether this disorder is primary or caused by cow's milk allergy.

IgG anti-betalactoglobulin (betalactotest): its usefulness in the diagnosis of cow's milk allergy

The aim of this prospective study was to evaluate the distribution of serum values of IgG anti-betalactoglobulin in 3 groups of subjects: a) 218 healthy subjects (138 M, 80 F) with age ranging from 1 month to 6 years; b) 205 patients with cow's milk protein allergy (CMPA) (130 M, 75 F) aged between 1 month and 4 years; c) 96 patients (50 M, 46 F) with symptoms compatible with CMPA, but suffering from other diseases (age range 1 month-6 years). The IgG anti-betalactoglobulin values were obtained using a new commercially available immunoenzymatic method. There was a marked difference in the distribution of IgG antibetalactoglobulin values in the 3 study groups. In healthy controls the value corresponding to the 5th centile was 5%, to the 50th centile 17%, to the 90th centile 48%. In the gastroenterological controls, 5th centile was 5%, 50th centile 15% and 90th centile was 56%. In the patients with CMPA, 5th centile was 27%, 50th centile 101% and 90th was 147%. The distribution of the values was therefore significantly different in the CMPA group from that of the other 2 groups (p < 0.0001). Plotting receiver operating characteristics curves, we have indicated a betalactotest value of 36% as a cut-off with the highest diagnostic accuracy (89% sensitivity, 85% specificity). We suggest that the betalactotest should be used to confirm diagnosis in patients with suspected CMPA; with a cut-off of over 48% we found only one false positive for diagnosis of CMPA in patients presenting other diseases with an identical clinical picture.

Immunologic and absorptive tests in celiac disease: can they replace intestinal biopsies?

The sensitivity and specificity of several immunologic and absorption tests were determined in infants with celiac disease (31 male, 39 female; median age, 2.6 years) in different phases of the disease and in a group of control subjects with chronic diarrhea of different etiologies (32 male, 28 female; median age, 1.2 years). Intestinal biopsy was performed both in the patients and in the controls as a 'gold standard' for the diagnosis. The anti-gliadin antibody (AGA) IgG values showed a sensitivity of 89% and a specificity of 47%; AGA IgA were 69% sensitive and 92% specific; anti-endomysial antibodies (EmA) were 100% sensitive and 97% specific; the xylose test was 71% sensitive and 53% specific; and the steatocrit test after a standard fatty meal was 73% sensitive and 42% specific. The authors conclude that the absorption tests cannot be used successfully in screening for celiac disease, owing to their low specificity. In contrast, EmA behavior was always in accordance with histologic findings in the various phases of celiac disease, and we would advise their use combined with AGA to obtain a sensitivity and specificity of 100%.

[Evaluation of the effectiveness of cisapride in the treatment of gastroesophageal reflux]

To evaluate the effectiveness of administration of oral cisapride in patients with gastro-esophageal reflux, we studied 25 children, aged 1 month-7 years (mean 16.2 months) affected with GER. At the time of diagnosis and 8 weeks after treatment, patients were clinically evaluated and underwent a 24-hour continuous esophageal pH-monitoring. After treatment a complete regression of symptoms was observed in 20/25 patients. Moreover we recorded a significant reduction in the percentage of reflux time (p < 0.0001) and in the Jolley score (p < 0.0001), a very accurate scoring system to evaluate the pH-metric tracing, after treatment. It is concluded that cisapride is a useful agent both for the relief of symptoms and for the improvement of pH-metric parameters in children with GER disease.

Gastric emptying in infants with gastroesophageal reflux. Ultrasound evaluation before and after cisapride administration

The present study aimed to evaluate gastric emptying in children with gastroesophageal reflux (GER) by means of real-time ultrasonography, on the basis of measurements of the cross-sectional area of the gastric antrum. Twelve children with GER were studied (seven males, five females; age range, 3-13 months) and compared with 12 normal control children (six males, six females; age range, 3-13 months). The diagnosis of GER was confirmed by 24-h esophageal pH-monitoring. The GER patients had a significantly greater antral area than the controls at 90, 105, and 120 min after eating a standard meal (cow's milk formula, 300 ml/m2 body surface area); in addition, final gastric emptying time was significantly greater in the patients than in the controls (145 +/- 36.9 versus 78.7 +/- 19.3 min; p less than 0.0025). After 8 weeks of treatment with cisapride (0.3 ml/kg, three times a day) 24-h esophageal pH-monitoring and ultrasonography studies were repeated in the patients. The total percentage reflux time was significantly lower (p less than 0.038), and ultrasonography showed a decreased antral area at all the various study times, with no significant difference between patients and controls; final gastric emptying time was also significantly lower than before treatment (p less than 0.009). Furthermore, in the GER patients there was a significant correlation between gastric emptying time and the sum of the various reflux times recorded in the 2 h after all meals over the 24 h.(ABSTRACT TRUNCATED AT 250 WORDS)

[Magnesium hydroxide and aluminum hydroxide in the treatment of gastroesophageal reflux]

Fifteen children with gastro-esophageal reflux took part in a treatment trial with a regimen of magnesium hydroxide and aluminium hydroxide for 8 weeks period (700 mmol/1.73 mq/die). All children were evaluated clinically and underwent a 24-hour continuous esophageal pH-monitoring both at diagnosis and after 8 weeks of treatment. After therapy 12/15 children were cured and 3/15 improved. Moreover the total percentage of time during which pH was less than 4, the number of reflux episodes and the number of refluxes lasting than 5' recorded during 24-hour continuous esophageal pH-monitoring were significantly reduced after treatment. The Authors conclude that antacids in large quantities are effective in medical treatment of gastro-esophageal reflux.