Associations between breastfeeding duration and adherence to complementary feeding recommendations in Scotland.

We aimed to describe how breastfeeding relates to adherence to complementary feeding (CF) recommendations, diet diversification and feeding skills development and whether sociodemographic factors explain any differences observed. The Scottish Maternal Infant and Nutrition Survey for infants aged 8-12 months collected breastfeeding history, CF practices, diet and sociodemographic data using a self-completion questionnaire. Non-healthful CF practices were starting CF < 6 months, any consumption of sugar-sweetened beverages (SSBs), sweet or salty snacks (treats) or unmodified cow's milk and regular consumption of commercial baby foods. Diet diversification and feeding skills were assessed by amount of self-feeding and number of food groups, meals and snacks eaten daily. Of the 2730 mothers, 20% were solely infant formula fed (IFF) and 48% continued breastfeeding ≥6 months. Compared to IFF babies, mothers who gave any breast milk ≥6 months were more likely to start CF ≥ 6 months compared to those IFF (66% vs. 37%) and less likely to give treats (15% vs. 45%), SSBs (11% vs. 20%) and commercial baby foods (31% vs. 53%). These associations remained highly significant (p < 0.001) even after sociodemographic factor adjustment. Despite starting CF later, infants breastfed ≥6 months ate the same number of food groups and meals as those IFF, were just as likely to self-feed purees and more likely to self-feed finger foods daily (87% vs. 81% p < 0.001). Mothers who breastfeed beyond 6 months adhere more to CF recommendations and start CF later compared to IFF, but their babies eat a similarly diverse diet and have similar feeding skills.

Does planning to mixed feed undermine breastfeeding?

Continued breastfeeding is important for infants' health, but it is unclear whether mixed feeding increases the risk of breastfeeding cessation. We aimed to explore associations of mixed feeding and lactation problems with early cessation of breastfeeding. We analysed data from mothers who completed the Scottish National Maternal and Infant Feeding Survey and had previously breastfed their infants. At age 8-12 weeks, mothers (N = 1974) reported their feeding history and intentions, lactation problems and reasons for giving formula milk. The main outcome measure was cessation of breastfeeding before 6-8 weeks and time to cessation. By 6 weeks, 65% had mixed fed at some point, 32% had ceased breastfeeding, 22% were currently mixed feeding and 46% were exclusively breastfeeding. Lactation problems before 2 weeks were common (65%), and strongly associated with stopping breastfeeding (relative risk [RR]: 3.23, 95% confidence interval [CI]: 2.0-5.3) and with mixed feeding (RR: 3.14, 95% CI: 2.5-4.0). However, even after adjustment for breastfeeding problems mothers who planned to mixed feed (RR: 3.39, 95% CI: 2.4-4.9) and those who introduced formula for practicalities (RR: 3.21, 95% CI: 2.3-4.4) were more likely to stop breastfeeding. These variables also predicted later lactation insufficiency (planned mixed feeding RR: 1.39, 95% CI: 1.0-2.0; formula for practicalities RR: 1.76, 95% CI: 1.3-2.3). Mothers who received specialist lactation support were less likely to cease breastfeeding (RR: 0.63, 95% CI: 0.5-0.9) but nonspecialist input was unrelated to risk of cessation (RR: 1.06, 95% CI: 0.2-4.9). In conclusion, choosing to mix feed an infant is strongly associated with stopping breastfeeding, even in the absence of lactation problems.

Acute effect of oat ß-glucan on the bioavailability of orange juice flavanones.

The impact of ß-glucan on the bioavailability of orange juice (OJ) flavanones was investigated in a randomised controlled trial. Volunteers consumed 500 mL of OJ without or with either 3 g (OB-3) or 6 g (OB-6) of ß-glucan. Urine samples, collected 12 h before and over a 0-24 h period post-supplementation, were analysed by high-performance liquid chromatography-high resolution mass spectrometry. The overall 0-24 h urinary excretion of the 17 flavanone metabolites identified and quantified in urine after OJ ingestion corresponded to 29.7 µmol, and 25.0 and 9.3 µmol, respectively, after OB-3 and OB-6 intake. This corresponds to 9.3, 7.9, and 2.9% recoveries of the 318 µmol of the ingested flavanones. The acute ingestion of OJ with 6 g, but not 3 g of ß-glucan led to a significant reduction (p < 0.05) in the excretion of flavanone metabolites compared with consumption of OJ alone.

Prevalence and overlap of known undernutrition risk factors in children in Nairobi Kenya.

We aimed to describe the co-occurrence of known risk factors for undernutrition and the prevalence of modifiable risks in wasted, stunted and healthy children. Quota sampling was used to recruit healthy [weight for age Z scores (WAZ) > -2 SD] and undernourished [weight for length (WLZ) or WAZ scores ≤ -2 SD] children aged 6-24 months from seven clinics in low-income areas of Nairobi. Structured interviews were used to identify exposure to socioeconomic, water and hygiene, infant feeding, dietary and behavioural risks (low interest in food, high food refusal and force feeding). We recruited 92 wasted WLZ ≤ -2 SD, 133 stunted (length for age Z scores LAZ ≤ -2 SD) and 172 healthy (LAZ and WLZ > 2SD) children. Nearly all children were exposed to hygiene risks (90%) and low dietary diversity (95%) regardless of nutritional status. Stunted children were more likely to be exposed to socio-economic risks (54% healthy, 64% wasted and 72% stunted; P = 0.001). Compared with healthy children, wasted and stunted children were more likely to be exposed to infant feeding (25% healthy, 40% wasted and 41% stunted; P = 0.02) and behaviour risks (24% healthy, 49% wasted, and 44% stunted; P = 0.004). Overall, wasted and stunted children were twice as likely to be exposed to more than three risks (23% healthy, 48% wasted, and 50% stunted; P = <0.001). They were also more likely to be exposed to more than three modifiable risks (dietary, handwashing and behaviour risks). Wasting and stunting are associated with exposure to multiple risk factors, many of which are potentially modifiable using targeted advice.

Saturated and monounsaturated fatty acids in membranes are determined by the gene expression of their metabolizing enzymes SCD1 and ELOVL6 regulated by the intake of dietary fat.

PURPOSE: We investigated the effect of dietary fats on the incorporation of saturated (SAFAs) and monounsaturated dietary fatty acids (MUFAs) into plasma phospholipids and the regulation of the expression of lipid-metabolizing enzymes in the liver. METHODS: Mice were fed different diets containing commonly used dietary fats/oils (coconut fat, margarine, fish oil, sunflower oil, or olive oil) for 4 weeks (n = 6 per diet group). In a second experiment, mice (n = 6 per group) were treated for 7 days with synthetic ligands to activate specific nuclear hormone receptors (NHRs) and the hepatic gene expression of CYP26A1 was investigated. Hepatic gene expression of stearoyl-coenzyme A desaturase 1 (SCD1), elongase 6 (ELOVL6), and CYP26A1 was examined using quantitative real-time PCR (QRT-PCR). Fatty acid composition in mouse plasma phospholipids was analyzed by gas chromatography (GC). RESULTS: We found significantly reduced hepatic gene expression of SCD1 and ELOVL6 after the fish oil diet compared with the other diets. This resulted in reduced enzyme-specific fatty acid ratios, e.g., 18:1n9/18:0 for SCD1 and 18:0/16:0 and 18:1n7/16:1n7 for ELOVL6 in plasma phospholipids. Furthermore, CYP26A1 a retinoic acid receptor-specific target was revealed as a new player mediating the suppressive effect of fish oil-supplemented diet on SCD1 and ELOVL6 hepatic gene expression. CONCLUSION: Plasma levels of MUFAs and SAFAs strongly reflect an altered hepatic fatty acid-metabolizing enzyme expression after supplementation with different dietary fats/oils.

Eating and feeding behaviours in children in low-income areas in Nairobi, Kenya.

Child eating and caregiver feeding behaviours are critical determinants of food intake, but they are poorly characterized in undernourished children. We aimed to describe how appetite, food refusal and force-feeding vary between undernourished and healthy children aged 6-24 months in Nairobi and identify potential variables for use in a child eating behaviour scale for international use. This cross-sectional study was conducted in seven clinics in low-income areas of Nairobi. Healthy and undernourished children were quota sampled to recruit equal numbers of undernourished children (weight for age [WAZ] or weight for length [WLZ] Z scores ≤2SD) and healthy children (WAZ > 2SD). Using a structured interview schedule, questions reflecting child appetite, food refusal and caregiver feeding behaviours were rated using a 5-point scale. Food refusal and force-feeding variables were then combined to form scores and categorized into low, medium and high. In total, 407 child-caregiver pairs, aged median [interquartile range] 9.98 months [8.7 to 14.1], were recruited of whom 55% were undernourished. Undernourished children were less likely to 'love food' (undernourished 78%; healthy 90% p = < 0.001) and more likely to have high food refusal (18% vs. 3.3% p = <0.001), while their caregivers were more likely to use high force-feeding (28% vs. 16% p = 0.03). Undernourished children in low-income areas in Nairobi are harder to feed than healthy children, and force-feeding is used widely. A range of discriminating variables could be used to measure child eating behaviour and assess the impact of interventions.

Does early introduction of solid feeding lead to early cessation of breastfeeding?

Mixed milk feeding increases the likelihood of breastfeeding cessation, but it is not known if solid feeding (SF) has the same effect. We have identified 10,407 infants breastfed for at least 8-10 weeks from three large U.K. studies (Avon Longitudinal Study of Parents and Children [ALSPAC; born 1990-1991], Southampton Woman's Survey [SWS; 1998-2008], and Infant Feeding Survey 2010 [IFS 2010]) to investigate the associations between early SF and breastfeeding cessation. In the earliest study (ALSPAC), 67% had started SF before the age of 4 months, but in the latest (IFS), only 23% had started before 4 months. Solid food introduction before 4 months was associated with stopping breastfeeding before 6 months in all three cohorts, with little effect of adjustment for maternal sociodemographic characteristics (Poisson regression, adjusted prevalence ratios: ALSPAC 1.55, [95% confidence interval 1.4, 1.8], SWS 1.13 [1.0, 1.3], IFS 1.10 [1.1, 1.3]). Using Cox regression, adjusted hazard ratios for breastfeeding cessation compared with SF after 5 months were 2.07 (1.8, 2.4) for SF before 4 and 1.51 (1.3, 1.8) at 4-5 months for ALSPAC and 1.25 (1.1, 1.5) and 1.15 (1.0, 1.3) for SWS. Earlier introduction of solids was associated with a shorter duration of breastfeeding, particularly in cohorts where earlier introduction of solids was the norm, with a dose-response relationship, which was not explained by background social characteristics. As mothers most commonly introduced solids in the month prior to the then recommended age, continuing to recommend deferring solids to the age of 6 months is important to support sustained breastfeeding.

Development of a biochemical marker to detect current breast milk intake.

The WHO recommends exclusive breastfeeding for 6 months, but despite interventions, breastfeeding rates remain stubbornly low. Financial voucher incentives have shown promise but require a biomarker for validation of intake. This study aimed to develop a simple biochemical assay of infant urine that would tell if an infant was receiving any breast milk to validate maternal report. Urine samples were collected and snap frozen from 34 infants attending with minor illness or feeding problems, of whom 12 infants were exclusively breastfed, nine exclusively formula fed, and 11 mixed breast/formula fed. High-performance anion exchange chromatography was used to identify discriminating patterns of monosaccharide composition of unconjugated glycans in a sequence of three experiments. The absolute concentration of all human milk oligosaccharides measured blind could detect "any breastfeeding" only with a sensitivity of 48% and specificity of 78%. Unblinded examination of N-acetylglucosamine (GlcNAc) measured as GlcNH2 after hydrolysis of GlcNAc improved sensitivity to 75% at the expense of a specificity of 28%. Estimation of the relative abundance of GlcNH2 (GlcNH2[%]) or the ratio of GlcNH2 to endogenous mannose (Man) improved accuracy. In a further blind experiment, the GlcNH2/Man ratio with a cut-off of 1.5 correctly identified all those receiving "any breast milk," while excluding exclusively formula fed infants. The GlcNH2/Man ratio in infant urine is a promising test to provide biochemical confirmation of any breastfeeding for trials of breastfeeding promotion.

Health staff understanding, application, and interpretation of growth charts in Nigeria.

We aimed to compare plotting accuracy and interpretation of weight gain patterns in average and small infants on road-to-health (RTH) and the new World Health Organization (WHO) growth charts in Enugu, Nigeria. Child health staff plotted standard weights on both formats. Twelve plotted charts were created, permutating three different weight trajectories (fast, steady, and slow) ending at two attained weights (average and small), with each plotted on both chart formats. Respondents were shown four of these charts and asked to describe the weight gain pattern shown and what action this pattern would prompt. There were 222 respondents, of whom 78% were hospital based; 54% were nurses, 32% medical doctors, and 13% nutritionists. Plotting accuracy was good on both the WHO and RTH charts, but rating of weight gain was generally poor. On the RTH chart, slow weight gain was correctly recognized in only 19% average and 35% small infants, and responses were not significantly associated with the pattern shown. On the WHO charts, slow weight gain was correctly recognized in 40% average and 65% small infants (p = .002 and <.001), but they were also more likely to rate small children with normal growth as slow weight gain. In a logistic regression model, final weight predicted a slow weight gain rating more strongly (OR = 2.4; 1.8-3.2) than an actual slow weight gain pattern (OR 1.8; 1.1-1.6). Health staff seemed unable to recognize slow weight gain and were influenced more by current weight than actual weight gain pattern, though the new WHO format improved recognition.

A Review About Lycopene-Induced Nuclear Hormone Receptor Signalling in Inflammation and Lipid Metabolism via still Unknown Endogenous Apo-10´-Lycopenoids.

Lycopene is the red pigment in tomatoes and tomato products and is an important dietary carotenoid found in the human organism. Lycopene-isomers, oxidative lycopene metabolites and apo-lycopenoids are found in the food matrix. Lycopene intake derived from tomato consumption is associated with alteration of lipid metabolism and a lower incidence of cardiovascular diseases (CVD). Lycopene is mainly described as a potent antioxidant but novel studies are shifting towards its metabolites and their capacity to mediate nuclear receptor signalling. Di-/tetra-hydro-derivatives of apo-10´-lycopenoic acid and apo-15´-lycopenoic acids are potential novel endogenous mammalian lycopene metabolites which may act as ligands for nuclear hormone mediated activation and signalling. In this review, we postulate that complex lycopene metabolism results in various lycopene metabolites which have the ability to mediate transactivation of various nuclear hormone receptors like RARs, RXRs and PPARs. A new mechanistic explanation of how tomato consumption could positively modulate inflammation and lipid metabolism is discussed.

Poor Infant Feeding Practices and High Prevalence of Malnutrition in Urban Slum Child Care Centres in Nairobi: A Pilot Study.

Little is known about the style and quality of feeding and care provided in child day-care centres in slum areas. This study purposively sampled five day-care centres in Nairobi, Kenya, where anthropometric measurements were collected among 33 children aged 6-24 months. Mealtime interactions were further observed in 11 children from four centres, using a standardized data collection sheet. We recorded the child actions, such as mood, interest in food, distraction level, as well as caregiver actions, such as encouragement to eat, level of distraction and presence of neutral actions. Of the 33 children assessed, with a mean age of 15.9 ± 4.9 months, 14 (42%) were female. Undernutrition was found in 13 (39%) children with at least one Z score <-2 or oedema (2): height for age <-2 (11), weight for age <-2 (11), body mass index for age <-2 (4). Rates of undernutrition were highest (9 of 13; 69%) in children aged 18-24 months. Hand-washing before the meal was lacking in all centres. Caregivers were often distracted and rarely encouraged children to feed, with most children eating less than half of their served meal. Poor hygiene coupled with non-responsive care practices observed in the centres is a threat to child health, growth and development.

Combined effects of added beta glucan and black tea in breads on starch functionality.

Bread and tea are usually consumed separately, but there may be different food-matrix interactions and changes in starch characteristics when they are combined in bread. This study developed breads (white bread, WF; black tea, BT; beta glucan, ßG; beta glucan plus black tea, ßGBT) and determined their starch functionalities. Breads were developed using a standard baking recipe and determined their starch characteristics. There was no significant difference in starch hydrolysis between BT and WF but ßGBT reduced early (10 min) starch hydrolysis compared with ßG. The starch granules in ßG and ßGBT were elliptical and closely packed together. These results suggest that the addition of beta glucan and black tea to bread preserved the elliptical starch granules and lowered short-term starch hydrolysis.

Evaluation of a cooking skills programme in parents of young children--a longitudinal study.

OBJECTIVE: To evaluate longitudinally the effectiveness of a cooking programme on self-reported confidence about cooking skills and food consumption patterns in parents of young children. DESIGN: An evaluation of cooking programmes delivered by National Health Service (NHS) community food workers using a single group pre-test/post-test repeated measures design. A shortened version of a validated questionnaire at baseline, post intervention and 1-year follow-up determined confidence in cooking using basic ingredients, following a simple recipe, tasting new foods, preparing and cooking new foods on consumption of ready meals, vegetables and fruit. SETTING: Deprived communities in Ayrshire and Arran, Scotland. SUBJECTS: Parents of nursery age children, 97 % were female and <45 years old. RESULTS: One hundred and two participants had completed baseline and post-intervention questionnaires. Forty-four participants contacted by telephone completed a follow-up questionnaire. In participants who completed all questionnaires (n 44), median confidence in four aspects of cooking increased significantly from baseline to post intervention (P < 0·001) but was retained at 1-year follow-up only for following a simple recipe and preparing and cooking new foods. Improved food consumption patterns were reported from baseline to post intervention (ready-meal consumption reduced from 2-4 times/week to 1 time/week, P < 0·001; vegetable consumption increased from 5-6 times/week to 1 time/d, P < 0·001; fruit consumption increased from 5-6 times/week to 1 time/d, P < 0·001) and remained at 1-year follow-up. CONCLUSIONS: The cooking programmes appeared to improve cooking confidence and food consumption patterns in the target group and some of these changes were retained after 1 year.

Increased FADS2-derived n-6 PUFAs and reduced n-3 PUFAs in plasma of atopic dermatitis patients.

Fatty acid concentrations, in particular n-3 and n-6 polyunsaturated fatty acids (PUFAs), have been described to be dysregulated in atopic dermatitis (AD) patients. The role of genetic polymorphisms of fatty acid enzymes in AD is controversial. We determined in a Hungarian cohort of healthy volunteers (n = 20) and AD patients (n = 20) triglyceride-, sterol- and phospholipid-bound fatty acids in the plasma, mRNA expression of fatty acid desaturase 2 (FADS2) and stearoyl-coenzyme A desaturase 1 in peripheral blood mononuclear cells (PBMCs) and FADS2 concentrations in plasma. We observed higher levels of monounsaturated fatty acids, 16:1 versus 16:0 ratios in phospholipids, triglycerides and sterol esters in patients compared to healthy subjects. In addition higher levels of the FADS2-derived n-6 PUFAs γ-linolenic acid and dihomo-γ-linolenic acid were observed in PBMCs of patients as well as lower levels of n-3 PUFAs. We conclude that the increased expression of FADS2 in PBMCs, as a representative tissue accessible from human blood of AD patients, might be responsible for higher levels of FADS2-derived n-6 PUFAs and lower n-3 PUFA levels in patients.

Association between Early Feeding Patterns and Neonatal Outcomes in Very Preterm Infants: A Retrospective Cohort Study.

OBJECTIVE: Mother's own milk (MOM) is the optimal feed for premature infants but may not always be sufficiently available. Alternative feeding includes donor human milk (DONOR), with or without fortification and preterm formula. This study evaluated the association between early feeding with exclusively and predominantly MOM (MAINLY-MOM) versus MOM supplemented with fortified DONOR (MOM + DONOR) or preterm formula (MOM + FORMULA) and in-hospital growth and neonatal morbidities. METHOD: This was a multicentre (n = 13 units) cohort study of infants born at <32 weeks' gestation. Data captured at the point of care were extracted from the UK National Neonatal Research Database. The study groups were defined based on feeding patterns within the first 2 weeks of life using predefined cut-offs. The primary outcome was the in-hospital growth rate. RESULTS: Data from 1,272 infants were analysed. Infants fell into two groups: extremely preterm (EPT) infants and very preterm (VPT) infants, born after <28 weeks and 28 to <32 weeks of gestation, respectively. Only 11 of 365 EPT infants received formula supplements, precluding a useful comparison of MOM + DONOR and MOM + FORMULA. There was no difference in median (25th-75th centile) growth velocity over the first 30 days of life between the MAINLY-MOM (n = 248) and MOM + DONOR (n = 106) groups: 10 (8-13) versus 10 (7-13) g/kg/day. Similarly, for VPT infants, there was no difference in growth velocities between MAINLY-MOM (n = 407), MOM + DONOR (N = 196), and MOM + FORMULA (N = 304): 11 (8-14) versus 11 (8-14) versus 11 (8-14) g/kg/day. Head growth did not differ (p value = 0.670). Cox regression analysis showed no difference in time to discharge between feeding types or any difference in major neonatal morbidities. In both EPT and VPT infants, growth velocity from the time of regaining birth weight to discharge was significantly lower in the MAINLY-MOM group compared to the MOM-DONOR group (EPT: 12.5 [11-14.2] vs. 14 [12.3-15.9] p = 0.45, VPT 13.5 [11-15.7] vs. 14.5 [12.6-16.8] p = 0.015). CONCLUSION: Early feeding with fortified DONOR, in comparison to formula, to supplement MOM was not associated with any differences in short-term growth, length of stay, and neonatal morbidities. However, early feeding with mainly maternal milk, compared to maternal milk supplemented with DONOR, was associated with significantly lower overall weight gain.

Bioavailability of orange juice (poly)phenols: ß-glucan-rich oat bran decreases urinary excretion of flavanone phase II metabolites and enhances excretion of microbiota-derived phenolic catabolites.

The impact of ß-glucan-rich oat bran on the bioavailability of orange juice (OJ) flavanones was investigated. Volunteers consumed 500 mL of OJ with and without 22 g of oat bran containing 6 g of ß-glucan (OB-6). Urine collected 12 h prior to and over a 0-24 h period post-supplementation was analysed by UHPLC-HRMS. Sixteen flavanone metabolites and thirty-nine colon-derived phenolic catabolites were identified and quantified. The major compounds were hesperetin-3'-glucuronide, along with hippuric acids and the C6-C3 phenolic acids 3-(3'-hydroxy-4'-methoxyphenyl)hydracrylic acid and 3-(4'-hydroxy-3'-methoxyphenyl)propanoic acid. A marked reduction in the 0-24 h excretion of flavanone metabolites from 29.7 µmol (9.3% recovery) to 9.3 µmol (2.9% recovery), occurred following consumption of OB-6 compared to OJ. This appeared not to be an effect of fiber on the rate of transport in the upper gut. After consumption of OJ there was a 163 ± 15 µmol excretion of colon-derived phenolic catabolites, equivalent to 43% of (poly)phenol intake and following OB-6 intake there was a further significant 30% increase. The ß-oat bran in OB-6 contained 5.8 µmol of free and 52 µmol of bound phenolic derivatives compared to 371 µmol of OJ (poly)phenols. The elevated excretion of phenolics after OB-6 consumption appears not to be due to bound phenolics in the bran, rather it is consequence, principally, of a bran-mediated increase in the quantities of flavanones passing from the upper to the lower bowel where they were subjected to microbiota-mediated catabolism. CLINICAL TRIAL REGISTRATION NUMBER: This trial was registered at clinicaltrials.gov as NCT04867655.

Interactions between dietary fibre and the gut microbiota.

Research characterising the gut microbiota in different populations and diseases has mushroomed since the advent of next-generation sequencing techniques. However, there has been less emphasis on the impact of dietary fibres and other dietary components that influence gut microbial metabolic activities. Dietary fibres are the main energy source for gut bacteria. However, fibres differ in their physicochemical properties, their effects on the gut and their fermentation characteristics. The diversity of carbohydrates and associated molecules in fibre-rich foods can have a major influence on microbiota composition and production of bioactive molecules, for example SCFAs and phenolic acids. Several of these microbial metabolites may influence the functions of body systems including the gut, liver, adipose tissues and brain. Dietary fibre intake recommendations have recently been increased (to 30 g daily) in response to growing obesity and other health concerns. Increasing intakes of specific fibre and plant food sources may differentially influence the bacteria and their metabolism. However, in vitro studies show great individual variability in the response of the gut microbiota to different fibres and fibre combinations, making it difficult to predict which foods or food components will have the greatest impact on levels of bioactive molecules produced in the colon of individuals. Greater understanding of individual responses to manipulation of the diet, in relation to microbiome composition and production of metabolites with proven beneficial impact on body systems, would allow the personalised approach needed to best promote good health.

Development of a Scale to Measure Infant Eating Behaviour Worldwide.

In order to create a short, internationally valid scale to assess eating behaviour (EB) in young children at risk of undernutrition, we refined 15 phrases describing avidity or food refusal (avoidance). In study one, 149 parents matched phrases in English, Urdu, Cantonese, Indonesian or Greek to videos showing avidity and avoidance; 82-100% showed perfect agreement for the avidity phrases and 73-91% for the avoidant phrases. In study two, 575 parents in the UK, Cyprus and Indonesia (healthy) and in Kenya, Pakistan and Guatemala (healthy and undernourished) rated their 6-24 months old children using the same phrases. Internal consistency (Cronbach's α) was high for avidity (0.88) and moderate for avoidance (0.72). The best-performing 11 items were entered into a principal components analysis and the two scales loaded separately onto 2 factors with Eigen values > 1. The avidity score was positively associated with weight (r = 0.15 p = 0.001) and body mass index (BMI) Z scores (r = 0.16 p = 0.001). Both high and low avoidance were associated with lower weight and BMI Z scores. These scales are internationally valid, relate to nutritional status and can be used to inform causes and treatments of undernutrition worldwide.

Early versus Delayed Fortification of Human Milk in Preterm Infants: A Systematic Review.

Expressed breast milk (EBM) is commonly supplemented with commercially prepared human milk fortifier to meet the additional nutritional needs of preterm infants. The optimal milk intake at which to introduce fortification is unknown. The objective of this systematic review was to compare the effect of early fortification (EF) versus that of delayed introduction of human milk fortifier (DF) on short-term outcomes including growth, feeding intolerance, length of hospital stay, and maturity at discharge in very-low-birth-weight infants. The search was carried out until March 2019 using 5 electronic databases (PubMed, Ovid Medline, Web of Science, Ovid Embase, and the Cochrane Library). The search was supplemented with a search of the clinical trial registry and reference lists. Eligible studies involved randomized controlled trials that had been designed to compare EF against DF using multi-nutrient fortifier for infants of a birth weight of <1,500 g who were fed exclusively or predominantly EBM. Four authors independently screened the studies for eligibility. A total of 1,972 articles were screened; 2 studies met the inclusion criteria and were included with a total number of participants of 171. The definition of EF and DF was not consistent between the 2 studies. There was no significant impact of EF versus DF on all outcomes. In conclusion, current data are limited and do not provide evidence on the optimal time to start fortification. The definition of EF and DF needs to be agreed upon and further larger randomized controlled trials are required.