Probiotics are live micro-organisms that survive passage through the gut and bring benefits in terms of immune system modulation and protection against pathogenic bacteria. May be normal gut flora! Typically lactobacilli and bifidobacteria, althouth yeasts such as saccharomyces also used. Predominate in the normal flora of breast fed babies; not in such high numbers in adults. Considerable differences in species and strains eg gut permeability, IgA levels. Regular yogurts have low colony counts of bacteria that survive pasteurization, and the specific strains may be different from those researched.
Adherence may prevent binding of toxogenic bacteria eg lactobacillus acidophilus and some bifidobacteria. Also antimutagenic (see below). Interact with immune system at many levels including cytokine production, mononuclear cell proliferation etc. Produce lipopolysaccharide and other substances, which bind to epithelium, and can act as carriers for other antigens. (No evidence for prebiotics).
Evidence:
PIDJ 24(3)March 2005 pp 267-268, Teitelbaum, Jonathan E. MD
Prebiotics are non-digestible oligosaccharides that selectively stimulate the growth of probiotic-like bacteria. Artichokes, onions, chicory, garlic, leeks (and cereals, legumes to a lesser extent). No clinical studies on diarrhoea prevention. Both appear to be antimutagenic: bind pyrolysates (deep fat frier oil) and degrade carcinogens such as N-nitrosamines.
Double-blind, placebo-controlled, RCT of prophylactic Bifidobacterium lactis, Lactobacillus reuteri, or no probiotics (n = 201). Controls had significantly more febrile episodes, more diarrhea with episodes of longer duration. The L reuteri group had significantly less days with fever, clinic visits, child care absences, and antibiotic prescriptions. Pediatrics. 2005 Jan;115(1):5-9.
Regulator of gene expression and cell differentiation. Deficiency causes alteration in balance of Th1 and Th2 type responses.
Vitamin A supplementation at 6-72 months improves survival in populations with endemic deficiency. In Asia, neonatal supplementation (on days 1 and 2) reduced early IMR (in Tamil Nadu by 22%, with benefit up to 3 months), but in Africa it did not. In the former case, high IMR, and maternal night blindness common. In contrast, African sites probably did not have much deficiency and IMR was not that high either. Giving supplements later, with DTP, does not appear to produce benefit – why?
Prolonged breast feeding as risk factor. 2nd peak of vit D def in adolescence - body pain!
CMO letter '05 recommends vits suppls to all under 5s - in Birmingham study about 1/3 of young infants with hypocalcaemia formula fed!
Prevention - NICE says no evidence for suppls in pregnancy/breast feeding (recommended though!). 1 bottle Abidec lasts 8-10/52, costs ?1.50 from Nhs, but not appropriate for pregnancy because of Vit A dose. NHS Mother + Child drops withdrawn last year.
Iron supplementation reduced unexplained fatigue in non-anaemic women! Probably best for borderline iron deficiency.
Iron deficiency is related to poor food intake, early cow's milk and high fruit juice intake. DOH recommends 300 ml milk at 1 year. WHO definition of anaemia is Hb <11 up to 2 yrs, 11.2 under 6 yrs. Use of formula until 18 months is effective but free milk tokens only available up to 1 yr. DOH recommends vitamins from 6 months to 2 years, and until 5 yrs in vulnerable children, especially if not on formula.
Zinc supplementation reduces morbidity from diarrhoea and pneumonia in high risk populations. Works during and after diarrhoea, even up to 2–3 months without further supplementation. In RCT in Zanzibar, non significant 7% reduction in mortality (significant in 12-48 months). Lancet, Volume 369, March 2007, 927-934
Carbohydrate intake 3-4mg/kg/min recommended, max 5 (else excess converted to fat, hyperglycaemia). Up to 12 in neonates (use insulin if necessary).
Fat - Max IV 2.5g/kg/d.
Calories/protein - min 40 kcal/kg, 1g/kg protein for maintenance. For growth 80 kcal (pref 100), 2 g/kg pref 3 (3.5 in preterm). Lipid should not contribute more than 50% of calorles - potential for hyperlipidaemia, pulmonary hypertension, fatty liver, displaced bilirubin.
10% dextrose gives 34kcal/100ml, protein 40kcal/100g, lipid 11 kcal/ml.
Sodium requirement 1-3 mmol/kg, potassium 1-3 - hlgher requirement in catabolism.
Use ideal body wt?
Protein- 2 commercial kinds, Primine (higher concentration), and Vaminolact. The profile of both is based on cord blood (debatable which is best standard - what about breast milk?).
Intralipid is not ideal balance of FFA's, but all there is at the moment. Vitlipid is a mix of 10% lipid and fat soluble vitamins.
Peditrace is a mix of minerals. Added to TPN at the last minute as it reduces stability.
Use of Sodium free TPN in the first 24 hours allows for the expected contraction of the extra cellular fluid compartment.
TPN should be used with caution in acidosis, renal failure, unstable glucose.
Seen as parental failure to feed adequately, and as irreversible. Oral feeding seen simultaneously as difficult but a special, social time, and potentially enjoyable for the child. Feeding seen as being linked to speech development (debatable) so important for prognosis. Tests to determine safety of airway seen as less reliable than personal experience, esp in absence of coughing etc. Weight gain not always seen as likely (genetic disease) or desirable (in terms of lifting). Fundoplication not popular - major op, and irreversible. Again, reflux tests seen as unreliable.
(GOS qualitative study, Dev Med&Ch Neuro 2003)
Issues raised by families are time spent feeding (esp time taken away from rest of family), family stress esp siblings, importance of love as an essential factor in quality of life (for both child and parent). Weight gain is not as highly prioritised by families as it is by doctors, and parents report that they are often made to feel guilty. Most feel positive about gastrostomy, but reasons for resisting a gastrostomy included reluctance to deprive the child of enjoyment of food, a perception that a gastrostomy is unnatural, concern about operative/anaesthetic complications, or hearing negative reports from other parents. Many felt that accepting a gastrostomy meant failing or giving up on efforts to orally feed. Some of the parents of children with gastrostomies were very surprised that following gastrostomy their child was no longer interested in oral feeding and that what had been interpreted as enjoyment of food was actually hunger. Not many complained about caring for a heavy child. PMID 17932123
Giving toddlers a bottle makes it easier for them to drink - but encourages dependence on milk/juice. Cups should be encouraged.
Division of tongue tie in infancy improves feeding problems (RCT).
There is a general adverse effect of artificial food colouring and benzoate preservatives on the behaviour of 3 year old children which is detectable by parents but not by a simple clinic assessment. Double blind crossover study, with 1 week study periods. Prior levels of hyperactivity do not influence this adverse effect. (ArchDisChild 89;2004)
What nutrition works in the South? In a cluster-randomised trial, in a poor periurban area of Peru, three key educational messages were spread via existing health services: giving thick purees of complementary foods at each meal; adding chicken liver, egg, or fish; and use of responsive feeding-practices. The results of this intervention are impressive: a three-fold difference in stunting at 18 months (15% vs 5%) despite no difference in breastfeeding behaviours or child morbidity.
This intervention had a relatively strong apparent effect on linear growth, compared with previous studies: a parallel study in India with a similar study design showed a much smaller effect on linear growth (0.3 cm in India vs 1.0 cm in Peru). One key difference between the two studies is the emphasis on inclusion of non-milk animal-source foods in the infant's diet in Peru (in India, milk consumption was promoted).
This is consistent with the positive growth results from an intervention study in China in which daily consumption of eggs was promoted: perhaps animal-source foods are an essential component of complementary food diets, unless adequately fortified products are used. Animal-source foods are key contributors of iron and zinc, nutrients that are nearly always in short supply at this age. Zinc supplementation enhances child growth in stunted populations.
Low carbohydrate diets are associated with detrimental nutritional effects and a high rate of relapse. The glycaemic index (GI) is a system for classifying foods according to how much they affect blood sugar within 2 hours of consumption (area under the curve). Does not correlate with terms such as simple sugar and complex carbohydrate, strangely.
Most varieties of bread, rice, breakfast cereals, and potato products have a high GI because processing methods allow the starch to become fully hydrated and therefore rapidly hydrolysed into glucose in the human digestive tract. By contrast, non-starchy vegetables, legumes, nuts, and fruits have a low GI. Whole kernel and traditionally processed grain products, such as stoneground breads, steelcut oats, and pasta, tend to have a moderate GI.
Such diets are more complicated, but at least are not as restrictive cf low fat/carbohydrate so more sustainable, do not have detrimental health effects, and fit in pretty well with the usual high fibre, fruit and veg advice.
2003 Water Act allows health authority to request fluoridation. Done in some parts of W Midlands, Yorkshire, Tyneside. Fluoride in water is main source, ingestion of toothpaste by young children may be important. University of York review found lots of papers but poor quality, so although caries appears to be reduced, the size of the effect was uncertain. Difference observed is 5-22% (interquartile) but poorly stratified for confounders. Data on fluorosis was particularly poor, except at the highest levels eg 1ppm. Data on other side effects very hard (multiple testing vs inadequate power) yet of concern if exposing whole populations for lifetimes. Does it count as a medicine? Even if it occurs naturally at same levels? Should it therefore be subject to same drugs standards of proof? Autonomy vs public good? Claimed to reduce social inequality but no RCT evidence. (BMJ 2007; 335; 699)
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