ARA or no ARA in infant formulae, that is the question

Recently, the European Commission issued a Delegated Regulation updating the compositional and information requirements for infant and follow-on formulae that are to be applied at the latest in February 2021. This new regulation changes the status of docosahexaenoic acid (DHA) from an optional ingredient to a mandatory nutrient in these formulae at levels between 20 and 50mg/100kcal (0.5-1% of fatty acids). By contrast, arachidonic acid (ARA) becomes an optional nutrient. Following publication of the new regulation, global scientific experts have expressed concerns regarding the potential health risks of new infant formulae containing only DHA, especially at levels higher than those in breast milk and infant formulae marketed to date. Both DHA and ARA play a crucial role in infant development. First, breast milk, the gold standard for infant feeding, contains both DHA and ARA. Second, during development, the conversion of linoleic acid into ARA through desaturation steps is not sufficient to meet nutritional needs, especially in carriers of newly identified genetic variants in fatty acid desaturases, which weaken the biosynthetic production of ARA. Third, circulating levels of DHA and ARA in breastfed infants can only be matched with the addition of both fatty acids to formulae. And fourth, most studies performed to date have demonstrated that important physiological and developmental endpoints are sensitive to the ratio of dietary ARA:DHA. The precautionary principle applies when implementing the new EU regulation for infant and follow-on formulae. As a consequence, given the vulnerability of developing infants as well as the absence of conclusive evidence that formulae with at least 20mg DHA/100kcal, but no ARA, are safe and suitable to support the growth and development of infants similar to their breastfed peers, it remains necessary to still market formulas containing both ARA and DHA until proved otherwise.

Family history of atopy in infants with cow's milk protein allergy: A French population-based study

OBJECTIVES

This French multicenter, cross-sectional, observational study aimed to describe the family history of atopy in infants with cow's milk protein allergy (CMPA), and the related diagnostic approaches used by specialists in a real-life ambulatory setting.

PATIENTS AND METHODS

In total, 1674 infants with suspected CMPA [median age 4.5 months (range: 0.1-18.0), males 54%] were enrolled in the study by 466 private physicians (pediatricians: 97%). Family history of atopy was defined as a known history of atopy in at least one first- (father, mother, and/or sibling) and/or second-degree relative (grandparents, uncles, and aunts), as reported by parents to physicians.

RESULTS

Atopy in a first-degree relative was more common among infants with documented or high probability of CMPA (in 84% and 80% of cases, respectively, vs. the other subgroups, P=0.005). Most infants experienced digestive (92%) and skin (61%) symptoms suggestive of CMPA. Delayed reactions were reported in 64% of infants. According to a post-classification based on the results of previous diagnostic tests and procedures, 1133 infants (68%) had highly probable (52%) or documented CMPA (16%). In these infants, a history of atopy was reported in first- and/or second-degree relative(s) in 86% of cases (81% in first-degree relatives). Whatever the family history of atopy, the characteristics of the infants were similar, except for fewer pets in the case of negative family atopy (14% vs. 25%, P<0.001). Atopy in a parent was more frequent in infants who presented with the first signs suggestive of CMPA within the first 6 months of life vs. those with later first symptoms (75% vs. 65%, P=0.063).

CONCLUSION

This French study confirms the high rate of family history of atopy in first-degree relatives of infants with probable or documented CMPA.

[Gastroesophageal reflux and sleep position of infants. A survey conducted in France by 493 pediatricians]

BACKGROUND AND AIMS

The supine sleeping position with the head higher than the legs has no impact on regurgitations in infants. Inclined ventral decubitus decreases regurgitations but is associated with an increased risk of sudden infant death syndrome (SIDS). The LUNE study aimed to evaluate the impact of regurgitations on the choice of sleeping position by pediatricians and parents.

METHODS

Cross-sectional case-control study (ratio 1:1) conducted in France in 2013. A representative sample of pediatricians recruited 3-week to 4-month-old breast- or formula-fed infants. Cases and controls were defined by the presence or absence of regurgitations. Collected data included Vandenplas codification for regurgitations (VD, range 0-6), associated symptoms, and variations in sleeping position since maternity hospital discharge.

RESULTS

A total of 1347 cases and 1346 controls were recruited by 493 pediatricians. Regurgitations were evaluated at VD1 (minor, 22 % of cases), VD2 (mild, 47 % of cases), or VD≥3 (moderate to severe, 31 % of cases). At the maternity hospital, the supine position was recommended to 96 % of parents for SIDS prevention. Since discharge, parents asked questions about the relationship between sleeping position and regurgitations (79 % of infants with GER versus 45 % of controls). The sleeping position was modified at least once since maternity discharge (42 % of infants with GER versus 35 % of controls). At inclusion, 86 % of infants with GER and 86 % of controls were sleeping on their back. Fifty-one percent of infants with GER and 28 % of controls slept in an inclined position. Pediatricians repeated the prescription of dorsal decubitus for 91 % of infants with GER and recommended an inclined position in 70 %.

CONCLUSIONS

Regurgitations had no impact on supine sleeping position. The inclined supine sleeping position was more frequent in infants with regurgitations with pediatricians' assent, which is not in agreement with evidence-based medicine.

[Capsule endoscopy in children: which are the best indications?]

BACKGROUND AND STUDY AIMS

Capsule endoscopy (CE) is a novel and noninvasive means of investigating the small bowel. In children, the best CE indications have not yet been fully appraised. The aim of this study was to evaluate the diagnostic yield of CE in different pediatric pathologies.

PATIENTS AND METHODS

We retrospectively reviewed every CE performed in children in two French pediatric hospitals between March 2002 and June 2009. Seventy-nine CEs were performed on 70 children (mean age, 10.6 years; range, 2.2-18.0); 52 boys and 18 girls. The indications were iron deficiency anemia (24%), obscure gastrointestinal bleeding (14%), polyposis syndromes (16%), suspected Crohn disease (15%), unresponsive Crohn disease (10%), graft-versus-host disease (10%), and other (10%).

RESULTS

Of the 79 CEs, 69 reached the cecum (87%). Only one occlusion occurred in a case of stenosing Crohn disease, requiring surgical removal. In addition, technical difficulties led to an incomplete small bowel study in 12 cases (16%). The CE showed small bowel lesions in 42 cases (53%). The diagnostic yield was 27% in obscure gastrointestinal bleeding, 37% in iron-deficiency anemia, 42% in suspected Crohn disease, 88% in unresponsive Crohn disease, 62% in polyposis syndromes, and 88% in graft-versus-host disease.

CONCLUSION

In children, CE is well tolerated and can be performed in children as young as 2.2 years of age. Its diagnostic yield is highest in polyposis syndromes, unresponsive Crohn disease, and graft-versus-host disease.

Treatments for pediatric achalasia: Heller myotomy or pneumatic dilatation?

AIM

The treatment of achalasia consists of reducing distal esophageal obstruction by either Heller myotomy surgery or endoscopic pneumatic dilatation. The aim of the present study was to evaluate the short- and middle-term results of these procedures in children.

METHODOLOGY

For technical reasons, children under six years old (n=8) were treated by surgery only, whereas patients over six years old (n=14) were treated by either Heller myotomy or pneumatic dilatation.

RESULTS

Of the children aged under six years, 75% were symptom-free at six months and 83% at 24 months of follow-up. Of the patients aged over six years, complete remission was achieved by Heller myotomy in 44.5% vs. 55.5% by pneumatic dilatation after six months, and in 40% vs. 65%, respectively, after 24 months. Both pneumatic dilatation and Heller myotomy showed significant rates of failure.

CONCLUSION

These results suggest that pneumatic dilatation may be considered a primary treatment in children over six years old. Also, where necessary, Heller myotomy and pneumatic dilatation may be used as complementary treatments.

[Ingestion of foreign bodies in children. Recommendations of the French-Speaking Group of Pediatric Hepatology, Gastroenterology and Nutrition]

Ingestion of foreign bodies is a common pediatric problem. The majority of ingested foreign bodies pass spontaneously. Management of foreign body ingestions varies based upon the object ingested, its location, and the patient's age and past history. Esophageal foreign bodies should be urgently removed because of their potential to cause complications. Ingested batteries that lodge in the esophagus, sharp or pointed foreign bodies in the esophageal or gastric tract, and ingestion of multiple magnets all require urgent endoscopic removal. Flexible endoscopy is the therapeutic modality of choice for most patients. The use of devices such as a latex protector hood or an overtube may facilitate safer extraction of sharp objects.

[Routine use of gene amplification for pertussis diagnosis in children]

OBJECTIVES

The resurgence of whooping cough observed in France convinced us to develop a specific PCR assay to detect B. pertussis in nasopharyngeal secretions in parallel of the culture. The aim of our study was to show the value of the PCR in routine diagnosis.

MATERIAL AND METHODS

From November 1996 to August 2000, in two hospitals located in the Yvelines (France), the children consulting for a cough compatible with the diagnosis of whooping cough were included in this study. A questionnaire including clinical, biological and radiological items was completed for each one of these patients. A culture of Bordetella and a detection by PCR of B. pertussis were carried out on each nasopharyngeal aspirate. The diagnosis of whooping cough was retained if the detection was positive in PCR and/or culture.

RESULTS

Among the 215 investigated children with suspected cases of whooping cough, the diagnosis was positive for 45 (20.9%), of which 39 were less than one year old (median: three months). Sixteen (35.5,%) were positive at the same time for both the PCR and the culture, 26 (57.8%) for only PCR and three (6.7%) for only culture. The PCR was positive in 93.3% of the cases. The results were obtained with an average time of 48 hours. The culture was positive in 61.2% of the cases with an average time of six days. The monthly distribution of the cases of whooping cough was very inhomogeneous and of epidemic appearance. The majority of the cases was located between two periods: 42% between November 1996 and September 1997 and 40% between November 1999 and August 2000. Among the infected children, 15 were less than two months old and were not yet vaccinated; among the 24 others infants, a delay in the vaccine calendar was noted in 50% of the cases. Four children between six and 14 years old were correctly vaccinated. The evolution was favourable in all the children.

CONCLUSION

The PCR due to its sensitivity, its specificity and its rapidity offers to the clinician a powerful tool for the diagnosis of whooping cough. Nevertheless, the culture must be associated with the PCR, in order to follow the epidemiology and the sensitivity to antibiotics of B. pertussis.

[Nosocomial rotavirus infections in a general pediatric ward: epidemiology, molecular typing and risk factors]

OBJECTIVES

Nosocomial rotavirus infections induce difficult problems for pediatric wards during winter epidemics. This prospective study was carried out to measure their incidence in a general pediatric ward by using epidemiological tools, clinical and molecular methods, and to examine the main factors increasing the risk of cross contamination.

MATERIAL AND METHODS

The study was carried out on children, younger than three years old, hospitalized between 15 November 1996 and 1 March 1997. We examined the feces of all children for rotavirus on admission and during their hospital stay if they had developed diarrhea. The strains were typed by RNA electrophoresis. A cohort study was done to identify the factors of exposure to risk.

RESULTS

Three hundred twenty-six of the 415 hospitalized infants were studied. One hundred and five were hospitalized for gastroenteritis, including 39 (37.1%) with rotavirus infection. Among 221 infants admitted without diarrhea, 11 (5.0%) had an asymptomatic community infection and nine (4.3%) developed nosocomial gastroenteritis. The only significant predisposing factor (P = 0.003) for nosocomial infection was the distance between the hospital rooms and the nurses station. Despite the low level of typing (51%), the molecular study suggested a wide diversity of nosocomial and community strains.

CONCLUSION

The relatively low incidence of nosocomial infections found may be due to routine assignment to individual rooms, the isolation of infants admitted with acute diarrhea, and the policy of routine detection of asymptomatic carriers with the use of similar isolation measures for these children.

[Psychosomatic approach to encopresis]

Encopresis most often results from functional constipation and a behaviour disorder characterised by retention of faeces. Rarely it is a passive or active expulsion of normal faeces. It indicates a failure in the education of sphincter control, often with a preferential development of autoerotic versus relational investments. A depressive component is frequent. We propose a bidisciplinary approach with a somatic and psychological evaluation of the encopretic child from the first visit. The physical examination assesses constipation and stercoral stasis. Associated psychopathological symptoms or a pathogenic psychosocial situation must be sought. The therapeutic means must be directed towards the different etiologic features. Explanations of the physiopathology of the symptom and discussion with the child and the parents on the origin of the dysfunction must be accomplished first. A medical treatment of the constipation is generally indicated. Psychotherapy is initiated according to the background and associated psychopathological symptoms.