Home fortification with micronutrient sprinkles �C A new approach for the prevention and treatment of nutritional anemias

Despite global goals set by United Nations’ agencies over the past decade for significant reductions in iron deficiency anemia (IDA), it remains a largely unaddressed public health problem affecting more than two billion people, one-third of the world’s population. The negative impact of IDA on health and human potential are greatest in the developing world, where it is estimated that 51% of children younger than four years of age are anemic, mainly due to a diet that is inadequate in bioavailable iron. Studies in both developed and developing countries have consistently shown mental and motor impairments that may not be reversible in children younger than two years of age with IDA. From a public health standpoint there are four possible interventions for the prevention of anemia: dietary diversification to include foods rich in absorbable iron; fortification of staple foods including targeted fortification of complementary foods for infants and young children; the provision of iron supplements; and ‘home-fortification’. In response to a United Nations Children’s Fund (UNICEF) request to develop a new approach to IDA, our research group developed ‘Sprinkles’ for home-fortification of complementary foods. Sprinkles are single-dose sachets (like small packets of sugar) containing micronutrients in powder form (encapsulated iron, zinc, vitamins A, C and D, and folic acid), which are easily sprinkled onto any home-prepared complementary food. Sprinkles were developed to overcome many of the side effects and disadvantages of iron drops. We have demonstrated that Sprinkles are as effective as iron drops in the treatment and prevention of anemia. Sprinkles are easier to use and are, therefore, better accepted than iron drops, which may improve adherence to iron interventions.     

Child health in the new millennium

In today's modern, industrialized and affluent countries, like Japan and Australia, better living conditions and hygiene, plentiful nutritious food and rapid advances in biology and medical technologies have helped to bring about dramatic improvements in child health. The previous heavy burdens of infections and undernutrition have been eliminated or can now be controlled or effectively treated. In these countries, child health standards are higher than ever and expectation of life at birth is much higher than in the past. Some of the technological advances that have helped bring about this transformation are immunization, antimicrobial therapy, successful treatment of childhood leukemias, transplantation of vital organs and implementation of genetic diagnosis and gene therapy. The use of genetically modified foods and the prospects for cloning of humans are areas of intense interest and controversy. However, these advances have their disadvantages (e.g. antibiotic-induced drug resistance). Urbanization has encouraged the 'westernization' of dietary patterns and the long-term 'lifestyle diseases' that can follow in adults. Accidents, violence and drug abuse are major problems in many parts of the world. Changes in attitudes to sexuality and the spread of HIV/AIDS is another major problem, especially in Africa and Asia. Environmental pollution and the degradation of agricultural lands, rivers and seas are also important. Ironically, standards of child health and the prospects for long life in countries like Japan are better than ever before, but social and environmental changes are presenting children and their carers with new and unanswered challenges as we enter the 21 st century and the new millennium.     

Validity of a new food frequency questionnaire for pregnant women in the Norwegian Mother and Child Cohort Study (MoBa)

The aim of the present study was to examine the relative validity of foods and nutrients calculated by a new food frequency questionnaire (FFQ) in the Norwegian Mother and Child Cohort Study (MoBa). Reference measures were a 4-day weighed food diary (FD), a motion sensor for measuring total energy expenditure, one 24-h urine collection for analysis of nitrogen and iodine excretion, and a venous blood specimen for analysis of plasma 25-hydroxy-vitamin D and serum folate. A total of 119 women participated in the validation study, and 112 completed the motion sensor registration. Overall, the level of agreement between the FFQ and the FD was satisfactory, and significant correlations were found for all major food groups and for all nutrients except vitamin E. The average correlation coefficient between the FFQ and the FD for daily intake was 0.48 for foods and 0.36 for nutrients, and on average, 68% of the participants were classified into the same or adjacent quintiles by the two methods. Estimated total energy expenditure indicated that under-reporting of energy intake was more extensive with the FD than with the FFQ. The biological markers confirmed that the FFQ was able to distinguish between high and low intakes of nutrients, as measured by vitamin D, folate, protein and iodine. This validation study indicates that the MoBa FFQ produces reasonable valid intake estimates and is a valid tool to rank pregnant women according to low and high intakes of energy, nutrients and foods.     

Maternal and infant factors associated with reasons for introducing solid foods

The current UK Department of Health advice is to introduce solid foods to infants at around 6 months of age, when the infant is showing signs of developmental readiness for solid foods. However, many mothers introduce solid foods before this time, and for a wide variety of reasons, some of which may not promote healthy outcomes. The aim of the current study was to examine infant and maternal characteristics associated with different reasons for introducing solid foods. Seven hundred fifty‐six mothers with an infant aged 6–12 months old completed a questionnaire describing their main reason for introducing solid foods alongside demographic questions, infant weight, gender, breast/formula feeding and timing of introduction to solid foods. The majority of mothers introduced solid foods for reasons explicitly stated in the Department of Health advice as not signs of readiness for solid foods. These reasons centred on perceived infant lack of sleep, hunger or unsettled behaviour. Maternal age, education and parity, infant weight and gender and breast/formula feeding choices were all associated with reasons for introduction. A particular association was found between breastfeeding and perceiving the infant to be hungrier or needing more than milk could offer. Male infants were perceived as hungry and needing more energy than female infants. Notably, signs of readiness may be misinterpreted with some stating this reason for infants weaned prior to 16 weeks. The findings are important for those working to support and educate new parents with the introduction of solid foods in understanding the factors that might influence them.     

Controlling iron deficiency anemia through the use of home-fortified complementary foods

Iron deficiency anemia (IDA) is more common in South Asian countries including India, Bangladesh and Pakistan than anywhere else in the world. During infancy and early childhood, IDA is associated with impaired psycho-motor development and cognitive function that may be irreversible. As a consequence, there is a growing awareness that IDA is one of many factors impeding socio-economic prosperity of developing nations. The combination of unacceptably high prevalence rates and inadequate preventative programs highlights the need for new effective sustainable strategies to control IDA. The burden of iron deficiency can be reduced by taking a more holistic approach that would include promotion of healthy weaning practices and use of appropriate complementary foods, together with improving the nutritional value of such foods. There is an increasing body of peer-reviewed literature to support the contention that “micronutrient Sprinkles” is an effective strategy to improve the nutritional value of home-prepared complementary foods and thus to reduce the burden of iron deficiency among children. By combining data from recently conducted randomised control trials, Sprinkles were shown to be as efficacious as iron drops for treating childhood anemia. The iron in Sprinkles is well absorbed, and Sprinkles are easy to use and well accepted by young children and their caregivers. Integrated into existing public health programs, Sprinkles has the potential to improve the effectiveness of such programs.     

Social networks and infant feeding in Oaxaca, Mexico

The health benefits of delaying the introduction of complementary foods to infants' diets are widely known. Many studies have shown that mothers with the support of close social network members are more compliant with medical recommendations for infant feeding. In our study, we examine the effects of a broader spectrum of network members (40 people) on mothers' infant feeding decisions. The survey was conducted in Oaxaca, Mexico as part of a follow-up to a nationwide Mexican Social Security Institute survey of infant health. Sixty mothers were interviewed from a stratified random sample of the original respondents. Multivariate tests were used to compare the efficacy of network-level variables for predicting the introduction of 36 foods into infants' diets, when compared with respondent-level variables. The study yields four findings. First, network-level variables were better predictors of the timing of food introduction than socio-demographic variables. Second, mothers with more indigenous networks delayed the introduction of some grains (oatmeal, cereal, noodle soup, rice) and processed pork products (sausage and ham) to the infant's diet longer than mothers with less indigenous networks. Third, mothers who had stronger ties to their networks delayed the introduction of rice and processed pork products (sausage and ham) to the infant's diet longer than mothers who had weaker ties to their networks. Fourth, mothers who heeded the advice of distant network members introduced some grains (rice and cereal) earlier than mothers who did not heed the advice of distant network members.     

Commercial infant foods: content and composition.

The relative contribution of strained foods to total dietary caloric distribution is important when assessing the appropriateness of a particular food choice. Because protein intakes by most infants in the United States are generous, the high carbohydrate content of the typical strained food can be helpful in adjusting the distribution of calories. The fat content of most strained foods is low and those foods higher in fat are also comparatively high in protein content. Therefore it is difficult to find strained foods to contribute greater amounts of dietary fat without also increasing the percentage of calories in the form of protein. For this reason it is not possible to achieve a satisfactory distribution of calories in the diet of an infant fed skim milk. With the exception of home-prepared fruits with low sugar content, baby food prepared in the home will probably have a higher caloric density than commercial products. Care should be taken not to overfeed infants when feeding home-prepared baby foods. The appropriateness of United States baby foods for use in developing countries and a physiological rationale for age of introduction of strained foods were discussed. A basic need is to ensure that the strained foods of the future are formulated with emphasis given to nutritional need and least cost, as well as to mother's taste and to the manufacturer's profit.     

Is there a “complementary feeding cultural core” in rural Kenya? Results from ethnographic research in five counties

This investigation used data from focused ethnographic studies in five rural counties in Kenya to determine whether the concept of “special foods for infants and young children” exists in the different ethnic groups in these areas as an identifiable component of cultural beliefs and knowledge, as well as in practice, and whether they can be characterized as a “complementary feeding cultural core.” The concept of “cultural core foods” refers to the set of foods that have a central role in diets of a population and, as a consequence, also have significant social and emotional components. We used the ethnographic cognitive mapping technique of “free listing” and a qualitative 24‐hr recall of infants and young children (IYC) intake, with probing, to obtain data on caregivers' beliefs and behaviours. The results show that an IYC cultural food core can be identified in all of the counties. A related finding that supports the argument for an “IYC cultural core” with respect to appropriate foods for IYC is the clear cognitive consensus within sites about its content, although in practice, food insecurity and food shortage constrain household abilities to put their beliefs into practice. We conclude that interventions to improve IYC feeding in rural Kenya that build on the concept of “IYC cultural core foods” will be congruent with basic cultural ideas about managing IYC feeding and could take advantage of this cultural feature.     

Allergy, intolerance, and other adverse reactions to foods.

Adverse reactions (sensitivity) to foods are categorized as either allergic (immunologic) or intolerance (nonimmunologic). Some medical conditions caused by intolerance reactions have immunologic features, but these have not adequately explained the basis of these conditions. Idiosyncratic, toxic, and anaphylactoid reactions may resemble allergic reactions clinically even though they are not based on specific immunologic events. Complaints about adverse reactions to foods are common but most cannot be reproduced by challenge studies. This fact reflects the transient nature of many of these reactions and should prompt the pediatrician to be objective when diagnosing chronic or persisting conditions. Without objectivity, dietary avoidance measures potentially can have profound nutritional and psychosocial consequences. Negative skin-prick tests with foods have a high negative predictive value to rule out IgE-mediated mechanisms being operative. Skin-prick testing with cow's milk and hydrolysate formulas is useful in distinguishing mild "topical reactors" from the more severe "systemic reactors" and in selecting "hypoallergenic" formulas for their management. However, the DBPCFC is the "gold standard" that helps distinguish between reality and strongly held erroneous beliefs. This diagnostic test has established cow's milk, egg, peanut, and soybean as the foods most commonly responsible for allergic and intolerance reactions in children. The principles of management of these food-related conditions are similar. However, each food presents unique management issues to the pediatrician.     

Effects of a few food diet in attention deficit disorder.

Seventy-eight children, referred to a diet clinic because of hyperactive behaviour, were placed on a 'few foods' elimination diet. Fifty nine improved in behaviour during this open trial. For 19 of these children it was possible to disguise foods or additives, or both, that reliably provoked behavioural problems by mixing them with other tolerated foods and to test their effect in a placebo controlled double blind challenge protocol. The results of a crossover trial on these 19 children showed a significant effect for the provoking foods to worsen ratings of behaviour and to impair psychological test performance. This study shows that observations of change in behaviour associated with diet made by parents and other people with a role in the child's care can be reproduced using double blind methodology and objective assessments. Clinicians should give weight to the accounts of parents and consider this treatment in selected children with a suggestive medical history.     

Effects of a few food diet in attention deficit disorder

Seventy-eight children, referred to a diet clinic because of hyperactive behaviour, were placed on a 'few foods' elimination diet. Fifty nine improved in behaviour during this open trial. For 19 of these children it was possible to disguise foods or additives, or both, that reliably provoked behavioural problems by mixing them with other tolerated foods and to test their effect in a placebo controlled double blind challenge protocol. The results of a crossover trial on these 19 children showed a significant effect for the provoking foods to worsen ratings of behaviour and to impair psychological test performance. This study shows that observations of change in behaviour associated with diet made by parents and other people with a role in the child's care can be reproduced using double blind methodology and objective assessments. Clinicians should give weight to the accounts of parents and consider this treatment in selected children with a suggestive medical history.     

Which advises for primary food allergy prevention in normal or high‐risk infant?

In the last decades, international guidelines proposed different strategies of complementary foods introduction during weaning to prevent allergy. Avoidance measures, such as late introduction of allergenic foods, failed to show a significant preventive effect towards allergy. Recently, prospective randomized controlled studies suggested that the early introduction of solid foods ‐ rather than the late introduction ‐ could be a strategy to prevent allergic sensitization and food allergy. However, at today clear evidence of effectiveness and safety of early introduction are not yet available to recommend a radical change in the current clinical practice. A realistic advice for the general population could be to begin the weaning at 4–5 months with the progressive introduction of different foods. The advices for introduction of solid foods during weaning should also take in consideration the global development of child to chose the better timing of introduction of foods.     

Using the concept of Food Based Dietary Guidelines to Develop an Optimized Mixed Diet (OMD) for German children and adolescents

OBJECTIVE: To apply for the first time FAO/WHO standards for Food Based Dietary Guidelines (FBDG) to develop a total diet concept named Optimized Mixed Diet (OMD) for children and adolescents in a European country. METHODS: Exact 7-day menus were composed for sample age groups of children (4-6 years) and adolescents (13-14 years), taking into account the German meal patterns, common non-fortified foods, and sensory preferences of children (practical criteria). Food amounts and food selection within the menus were optimized so far as to achieve a total of reference intakes for 22 nutrients (scientific criteria). Simple food based messages were deduced. RESULTS: Compared to the existing high-fat, low plant food diet reported from the DONALD Study (Dortmund Nutritional and Anthropometric Longitudinally Designed Study), the OMD is lower in fat and saturated fatty acids and contains ample amounts of plant foods. Reference nutrient densities for age groups between 1 and 18 years were achieved or exceeded, except folate. Foods from the optimized menus were summarized into 11 food groups based on nutritional and practical considerations. Proportions of food groups by weight are independent of age and can be used to recalculate food amounts for various age groups or energy requirements, respectively. For simplification, "recommended" foods were distinguished from "tolerated" foods by their nutrient densities; based on food amounts, 3 simple rules for food consumption were deduced, i.e. beverages and plant foods: ample; animal foods: moderate; high-fat, high-sugar foods: sparingly. CONCLUSIONS: Exact menus and food amounts are a prerequisite to ascertain nutrient adequacy of FBDG. The OMD demonstrates that a single diet concept with a core of quantified food groups can be adequate for age groups between 1 and 18 years within a country, such as Germany.     

Feeding patterns of underweight children in rural Malawi given supplementary fortified spread at home

Fortified spread (FS), containing dry food particles embedded in edible fat, offers a convenient means for nutrition rehabilitation. To describe how caregivers feed FS to their undernourished children at home, and how FS use affects other feeding patterns, we conducted a longitudinal observational study in rural Malawi. Sixteen 6- to 17-month-old underweight children (weight-for-age z-score < -2.0; -3.0 < weight-for-height z-score < 0) received FS for 12 weeks. Twelve-hour observations were conducted before supplementation and during weeks 1, 4, 8 and 12 of FS use. FS was fed to children about two times per day; each serving was 15-20 g. The spread was first used mainly alone as a between-meal snack, and then became integrated into the typical complementary feeding pattern by being mixed with porridge. Introduction of FS reduced the number of plain porridge meals, but did not decrease the total number of meals or breastfeeds per day and did not change the daily mean time caregivers spent on feeding. Children accepted the FS well, but more FS was wasted when it was offered mixed with porridge than when given alone (23.6% vs. 1.2%, 95% CI for the difference 13.2% to 31.6%). FS supplementation is feasible for community-based nutrition interventions in Malawi because it easily becomes part of the feeding routine, does not replace other foods and does not take extra caregiver time. To limit wastage, caregivers should be advised to serve FS plain or to mix it with only a small quantity of porridge.     

Can my child with IgE-mediated peanut allergy introduce foods labeled with “may contain traces”?

Peanut IgE-mediated food allergy is one of the most common food allergies in children with a prevalence that has increased in the past decades in Westernized countries. Peanut allergies can trigger severe reactions and usually persist over time. Peanut-allergic children and their families are often confronted to processed foods with precautionary allergen labeling (PAL) such as “may contain traces of peanuts,” which are frequently used by the food industry. Patients are generally confused as to whether eating such foods entails a risk of allergic reaction, which can ultimately lead to dietary restrictions and decreased quality of life. Thus, guidance toward eviction of foods with PALs such as “may contain traces of peanuts” is a recurring problem that peanut-allergic patients address during pediatric allergy consultations with varying attitudes among allergists. Many studies have evaluated peanut contamination in foods with PALs, with generally less than 10% of foods containing detectable levels of peanuts, albeit heterogeneous amounts, with in rare occasions levels that could trigger allergic reactions in certain patients. The risk of reacting to foods with traces varies significantly with threshold, with patients with the lowest reaction thresholds at highest risk, and a dramatic reduction of risk as threshold increases. Thus, risk stratification based on individual reaction threshold may help stratify patients’ risk of reacting to foods with PAL. In clinical practice, a single-dose 30 mg peanut protein oral food challenge may be an option to stratify peanut-allergic patients’ risk when introducing foods with PAL, as illustrated by three clinical cases.     

Optimizing the introduction of complementary foods in the infant's diet: a unique challenge in developing countries

Being one of a series of technical support papers pertaining to the South African paediatric food-based dietary guidelines, this paper specifically deals with two of the guidelines proposed for the age group 6-12 months regarding the introduction of complementary foods in the infant's diet. Studies have shown that most of South African infants receive solid foods at the age of 4 months or earlier while only a small percentage are breastfed exclusively until 6 months. The untimely and inappropriate introduction of complementary foods have been shown to be risk factors for both under- and over-nutrition with resultant under- or overweight, stunting and micronutrient deficiencies. Optimal timing for the introduction of complementary foods will depend on the infant's physiological and developmental status. Small, frequent meals of easily digestable, smooth, semisolid nutrient- and energy-dense complementary foods should initially be offered while gradually increasing variety in both the type and texture of food. Protein and carbohydrate intake should increase with the infant's age while preference should be given to foods rich in micronutrients. It should be observed that certain foods, such as fresh cow's milk and egg white, because of their allergenic properties, as well as fat-free and high-fibre foods, excessive fruit juice and low nutrient value drinks such as tea are not recommended. Timely introduction of appropriate complementary foods is vital for the immediate and long-term health of the infant and caregivers should be accordingly advised on feeding at this age.     

The Aristotle method: a new concept to evaluate quality of care based on complexity

PURPOSE OF REVIEW: Evaluation of quality of care is a duty of the modern medical practice. A reliable method of quality evaluation able to compare fairly institutions and inform a patient and his family of the potential risk of a procedure is clearly needed. It is now well recognized that any method that purports to evaluate quality of care should include a case mix/risk stratification method. No valuable method was available until recently in pediatric cardiac surgery. RECENT FINDINGS: The Aristotle method is a new concept of evaluation of quality of care in congenital heart surgery based on the complexity of the surgical procedures. Involving a panel of expert surgeons, the project started in 1999 and included 50 pediatric surgeons from 23 countries. The basic score adjusts the complexity of a given procedure and is calculated as the sum of potential for mortality, potential for morbidity and anticipated technical difficulty. The Comprehensive Score further adjusts the complexity according to the specific patient characteristics (anatomy, associated procedures, co-morbidity, etc.). The Aristotle method is original as it introduces several new concepts: the calculated complexity is a constant for a given patient all over the world; complexity is an independent value and risk is a variable depending on the performance; and Performance = Complexity x Outcome. SUMMARY: The Aristotle score is a good vector of communication between patients, doctors and insurance companies and may stimulate the quality and the organization of heath care in our field and in others.     

The rise of technology in diabetes care. Not all that is new is necessarily better

Health‐care technologies have brought many benefits to the medical profession and to patients. The introduction of the continuous subcutaneous insulin infusion (CSII) pump and continuous glucose monitoring (CGM) devices offers patients with type 1 diabetes (T1D) the opportunity to optimize their blood glucose control and are increasingly being championed as a routine treatment approach for young people. However, the current evidence base does not convincingly support arguments for the generalized application of CSII and CGM into routine clinical practice. The ‘patient‐medical device interface’ is clearly a complex paradigm, and central to its success is the degree of adherence, understanding, and engagement demonstrated by the patient with the technology. The introduction CSII/CGM technologies into the daily routine care of the patient imposes both psychological and ‘time‐effort’ burdens that many patients and families with T1D will find demanding. The current application of these devices cannot therefore be considered a panacea for the self‐management of T1D, and raises a number of challenging problems, including those of a practical, health‐economic, and ethical nature that need to be fully resolved before it and other emerging technologies can be considered to have achieved this status.     

Health care use by children receiving mental health services

Reduction in medical care utilization is one criteria for assessing the impact of mental health treatment for children with psychosocial problems. This reduction has been termed the "offset" effect. Almost all published research concerning offset after mental health treatment concerns adults, and the few studies in pediatric populations are limited by methodologic problems. A study of health care utilization after mental health treatment for children was conducted. Mental health treatment for psychosocial problems was significantly associated with decreased use of medical care only for older children, after potentially confounding variables were controlled for. Furthermore, this decreased use was found only for nonmental health specialty care visits. No reduction in primary care visits occurred. Other factors such as previous patterns of use and the presence of other morbidity were stronger predictors of subsequent primary health care use than was mental health treatment. Mental health treatment does not have a major impact on the high utilization of most children with psychosocial problems in pediatric settings. Because the reasons for this may be particular morbidity patterns in these children, future studies should include some measure of case mix as a potentially important variable in assessment of mental health treatment effects.