Consensus on complementary feeding from the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition: COCO 2023.

Complementary feeding (CF) is defined as the feeding of infants that complements breastfeeding, or alternatively, feeding with a breast milk substitute, and is a process that is more than simply a guide as to what and how to introduce foods. The information provided by healthcare professionals must be up-to-date and evidence-based. Most of the recommendations that appear in the different international guidelines and position papers are widely applicable, but some must be regionalized or adapted to fit the conditions and reality of each geographic zone. The Nutrition Working Group of the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition (LASPGHAN) summoned a group of experts from each of the society's member countries, to develop a consensus on CF, incorporating, whenever possible, local information adapted to the reality of the region. The aim of the present document is to show the results of that endeavor. Utilizing the Delphi method, a total of 34 statements on relevant aspects of CF were evaluated, discussed, and voted upon.

Analysis of the Spanish national registry for pediatric home enteral nutrition (NEPAD): implementation rates and observed trends during the past 8 years.

BACKGROUND/OBJECTIVES: The home enteral nutrition (HEN) provides nutritional support to children with chronic diseases who are nutritionally compromised and allows them to be discharged more quickly from hospitals. In 2003, a web-based registry (Nutrición Enteral Pediátrica Ambulatoria y Domiciliaria, Pediatric Ambulatory and Home Enteral Nutrition -NEPAD-) was created with the objective of gathering information about pediatric HEN practices in Spain. AIM: The aim of this study was to report the implementation of the NEPAD (Nutrición Enteral Pediátrica Ambulatoria y Domiciliaria, Pediatric Ambulatory and Home Enteral Nutrition) registry of pediatric HEN in Spain and to analyze data evolution trends from 2003 to 2010. SUBJECTS/METHODS: The data from the Spanish NEPAD registry were analyzed according to the following variables: demographic data, diagnosis, indication for HEN, nutritional support regime and administration route. RESULTS: Over the study period, 952 patients (1048 episodes) from 20 Spanish hospitals were included in the NEPAD registry. The most frequent indication for HEN was decreased oral intake (64%), and neurological disease was the most prevalent illness. HEN was delivered via a nasogastric tube in 573 episodes (54.7%), by gastrostomy in 375 episodes (35.8%), oral feeding in 77 episodes (7.3%) and by jejunal access in 23 episodes (2.2%). Significant differences in the mode of administration were observed based on the pathology of the child (χ(2), P<0.0001). The cyclic feeding was the most widely used technique for the administration of HEN. Most of the patients used a pump and a polymeric formula. Transition to oral feeding was the primary reason for discontinuation of this type of support. CONCLUSIONS: Since the NEPAD registry was established in Spain, the number of documented patients has increased more than 25-fold. Many children with chronic illness benefit from HEN, mainly those suffering from neurological diseases.

Methemoglobinemia induced by vegetable intake in infants in northern Spain.

BACKGROUND AND OBJECTIVE: Acquired methemoglobinemia (MHb) induced in infants by intake of vegetables is a condition uncommonly reported in the literature. The purpose of the present study was to study new vegetables involved and other epidemiological risk factors. METHODS: Seventy-eight cases of diet-induced MHb seen in Pamplona from 1987 to 2010 are reported. Infant characteristics were collected, and a case-control study was conducted using as controls 78 age- and sex-matched infants selected at the same geographic area. Bivariate logistic regression analyses were performed to detect factors involved in MHb occurrence. Nitrate levels were tested in natural vegetables used to prepare purées. RESULTS: A clear relation was found between MHb and use of borage (Borago officinalis) (OR 5.2; 95% CI 1.1-24.6) and maybe chard (Beta vulgaris var cicla) (OR 2.0; 95% CI 0.4-8.7), time from preparation to use (OR 17.4, 95% CI 3.5-86.3 if the purée had been prepared 24-48 hours before and OR 24.9, 95% CI 3.3-187.6 if prepared >48 hours before), and breast-feeding (OR 10.4; 95% CI 1.9-57.2). Tests confirmed that vegetables with the highest nitrate levels were borage (n = 15), with mean nitrate levels of 3968 mg/kg, and chard (n = 17), with mean levels of 2811 mg/kg. CONCLUSIONS: The main associated factors were shown to be time from purée preparation to use (>24 hours), use of certain vegetables (borage and chard), and breast-feeding. Nitrate levels in both vegetables implicated as etiological factors in acquired MHb are high.

The impact of caesarean delivery and type of feeding on cow's milk allergy in infants and subsequent development of allergic march in childhood.

BACKGROUND: The incidence of IgE-mediated cow's milk allergy (CMA) has increased over the last few years. There are several genetic and environmental risk factors that may be related to this allergy and the subsequent allergic march (AM). METHODS: A prospective, cohort study was conducted in patients recruited into the study between 1998 and 2002. Information on clinical variables and complementary tests, perinatal and obstetric factors and the type of hydrolysed formula used was recorded. A cross sectional study on the prevalence of allergic diseases in this cohort was performed in 2004. RESULTS: We compared IgE-mediated CMA patients with non-IgE-mediated CMA patients and found that IgE-mediated CMA is associated with caesarean delivery (OR = 2.14 95% CI: 1.02-4.49), duration of breast feeding (>2 months, OR = 4.14; 95% CI: 2.17-7.89) and the use of supplementary artificial formula whilst breast feeding (OR = 2.86; 95% CI: 1.33-6.13). The factors associated with AM in IgE-mediated CMA patients were caesarean delivery (OR = 0.42; 95% CI: 0.19-0.92) and the use of more extensively hydrolysed high grade hydrolysates (+EH/HGH) (OR = 0.44; 95% CI: 0.20-0.98), both as protective factors. CONCLUSIONS: Caesarean delivery is demonstrated as being a risk factor for IgE-mediated CMA, but it does not increase the risk of AM in these infants. The use of +EH/HGH appears to protect IgE-mediated CMA patients from eventually developing AM.

[Rare diseases: medicine's challenge in the XXI Century]. / Enfermedades raras: el reto de la medicina en el siglo XXI.

Rare diseases (RD) are receiving increasing attention within both the scientific community and society in general. Many RDs are diagnosed during paediatric age and affect the patient throughout his life, but they can also be diagnosed during adult age. Advances in the biochemical, molecular and genetic diagnosis of these diseases are proving essential in improving clinical understanding and therapeutic possibilities. However, their low prevalence makes it difficult to develop suitable medicines for treatment and it is necessary to implement specific social and health protection programs for these medicines, which are called orphan medicines (OM). In general these serious, chronic diseases involving a high degree of disability are difficult to diagnose. For better diagnosis and monitoring it is necessary to develop reference units at the state level that will improve our knowledge of these pathologies. RDs have a direct repercussion on both the family, which in many cases becomes the carer, and on society, which must develop specific social, health and educational programs to support these patients. In short, RDs form a significant challenge of coordination for the scientific community and for society given their significant specific weight in the development of health care in our setting.

Modifying effect of HLA haplotypes located trans to DQB1*02-DRB1*03 in celiac patients of Southern Europe.

The DQ2 heterodimer, encoded by the human leukocyte antigen (HLA)-DQA1*05-DQB1*02 alleles, is the major genetic susceptibility factor for celiac disease (CD). However, the risk associated to HLA alleles varies among populations. While DRB1*03 is almost the only CD susceptibility allele in Northern Europe with a homozygote frequency of around 30%, CD in south European countries is also associated with the DRB1*07, and DRB1*03 homozygotes patients are rare. Some authors have suggested that DQB1*02-DRB1*03/DQB1*02-DRB1*03 and DQB1*02-DRB1*03/DQB1*02-DRB1*07 may confer different risk susceptibility to CD. This hypothesis, however, has not been demonstrated in a recent family-based study carried out in Finland, suggesting that the proposed differences in risk may be secondary to stratification burdens of case-control studies. To assess this issue, we have investigated the effect of different haplotypes carried trans to DQB1*02-DRB1*03 as additional factors for CD in Spain, using two statistical approaches, a case-control study and a family-based study. We found that DQB1*02-DRB1*03/DQB1*02-DRB1*03 and DQB1*02-DRB1*03/DQB1*02-DRB1*07 were the only combinations that showed a strong and independent association to CD. We did not observe any difference in susceptibility risk conferred by DQB1*02-DRB1*03 and DQB1*02-DRB1*07 when carried trans to DQB1*02-DRB1*03, suggesting that variation in HLA haplotype frequencies among populations may not represent real differences in risk to CD development. We also confirmed a gene dosage effect of the DQB1*02-DRB1*03 haplotype estimating that DQB1*02 homozygotes are at fivefold increased risk for CD compared with DQB1*02 heterozygotes. This risk is conferred by the second copy of the DQB1*02 allele and it seems to be independent of the DQA1.

[Breast-feeding in Navarra]. / Lactancia materna en Navarra.

The state of breast-feeding in our autonomous community between 1986 and 1993 is reviewed. Two comparable Navarrese neonatal groups from our main maternity hospital are studied. The prevalence of the different types of breast-feeding at the time of discharge from the maternity hospital is compared, as well as monthly rates until the sixth month of life. The following conclusions can be drawn from this study: 1. The category of breast-feeding in Navarra is type 1 of the WHO. 2. Breast-feeding is abandoned in an early and massive way throughout the first six months of life in Navarra, with figures for this practice being undetectable by the sixth month. 3. There are barely any significant differences between the figures for 1986 and 1993.

Heat-shock protein 70-1 and HLA class II gene polymorphisms associated with celiac disease susceptibility in Navarra (Spain).

Heat shock proteins (HSP) are thought to play a role in the immune response making probable their contribution to celiac disease (CD). We studied the polymorphisms in the 5' regulatory region of the HSP70-1 gene and performed genomic HLA-DQ and -DR typing in 128 CD patients and 94 healthy controls from Navarra (Spain). The frequency of the C allele of the HSP70-1, characterized by the intermediate electrophoretic mobility of DNA, was significantly increased among CD patients (64.5% vs 37.2%. p <1 x 10(-7)). When subjects were stratified by the HLA II genotype, differences were statistically significant between DR3-negative or DR3-DQB1*02-negative CD patients and matched controls. Homozygosity for the DQB1*02 allele was present in 48.4% of CD patients and 12.8% of controls (OR = 6.4; CI:3.1 to 13.8; p <1 x 10(-7)). Similar increased risk was observed for DQB1*02/*02, DRB1*03/-, or DRB1*03/07 patients. Furthermore, those individuals expressing the classical HLA alleles in CD (DQB1*02/*02, DRB1*03/*07) who also carried the HSP70-1 CC genotype were twelve times more likely to develop the disease than the matched controls. We therefore conclude that although HSP70-1 gene does not seem to be primarily associated with CD, it might be a component of the high risk haplotype, playing a role as an additional predisposing gene for the disease.

[Measurement of stool composition in children with celiac disease using near-infrared reflectance spectroscopy]. / Medida de la composición fecal en niños celiacos mediante espectroscopía de reflectancia en el infrarrojo cercano.

Celiac disease is a disorder caused by gluten-sensitivity which, when manifested in its classical digestive form, frequently presents a malabsorption syndrome. The aim of this study is to evaluate the faecal composition in celiac children with malabsorption syndrome at the moment of diagnosis by using near-infrared reflectance spectroscopy and to compare it with that of healthy children. Thirty children with biopsy-proven celiac disease and 86 age-matched control children were recruited in our study. Children collected 24 hour faecal specimens and the analyses of faeces, water, fat, nitrogen and sugar were performed using near-infrared reflectance spectroscopy. Results show that celiac children daily eliminate a significantly greater quantity of water, fat, nitrogen and sugar than those in the control group. This might be due to the higher weight of faeces eliminated in the celiac group and, of course, to their celiac condition. Of all the nutrients, faecal fat is the substance which undergoes the greatest change, indicating that this nutrient continues to be the best parameter for dealing with patients with malabsorption syndrome. Near-infrared reflectance spectroscopy appears to be a useful tool for assessing stool composition in celiac disease.

[Infant mortality and sudden infant death in Navarra between 1985 and 1996]. / Mortalidad infantil y mortalidad por muerte súbita infantil en Navarra 1985-1996.

OBJECTIVE: The objective of this study was to obtain an accurate register of the deaths of children less than one year of age in order to discover the real infant mortality (IM) rate in Navara and its trend during the period between 1985 and 1996, a well as to investigate the deaths by sudden infant death (SID) in the same period and their relationship to the prone position during sleep. PATIENTS AND METHODS: Infant mortality was determined by detailed examination of all certified deaths. Research into possible nonregistered deaths was also carried-out. The sources of information included the archives and registers of the pediatric and obstetric wards and pathology departments of all hospitals. Deaths codified as 798.0 (CIE9 infinity R) were included in the study as death by SID. To determine sleeping posture. In the second semester of 1996, a survey was carried out on a sample of 285 children of under 6 months of age. The survey's model is the same as that published previously. RESULTS: In the period of 1985 to 1992, IM was 12.33 per thousand live births. The SID rate was 1.30/1,000 live births. The prevalence of the prone position is unknown. In the period between 1993 and 1996, IM decreased to 5.84/1,000 live births and this decrease was proportional in both the neonatal and postneonatal components. The rate of SIM decreased to 0.44/1,000 live births. At the beginning of 1993, 86% of the children slept in the prone position, in 1994, 38% and in 1996, only 23%. CONCLUSIONS: Trustworthy data in Navarra shows a decrease in IM of more than 50% from 1993 on. The SID rate also decreased by 65%, coinciding with a massive drop in the use of the prone position during sleep.

[Change of position and the decrease in the cases of sudden infant death syndrome in Navarra]. / Cambio de postura y disminución de la tasa de mortalidad por muerte súbita infantil en Navarra.

The prone position during sleep has been described as the most important risk factor in relationship to sudden infant death syndrome (SIDS). The prevalence of infants that sleep in the prone position and its relationship with SIDS has not been studied in our country. A survey was performed in a population of children born in Navarra between February 1, 1992 and February 1, 1993. We found that 86.5% of these children sleep in the prone position, 5.6% in the supine position and 3.5% on their side. In March 1993 a campaign was begun that recommended that the prone position not be used for infants from the time of birth until 6 months of age. After this campaign, in a sample of 441 children, born between May 1, 1993 and May 1, 1994, only 38.3% of the infants continued to sleep in the prone position, while 46% did so supine and 9% slept on their side. The number of deaths in Navarra as a result of SIDS during the period of 1985 through 1993 was 1.3% of live births with a mean of 6.3 deaths/year. The number of infant deaths after the change of sleeping position, in 1994, was 0.42% of live births, with 2 deaths as a result of SIDS during this year. In Navarra, the decrease in the number of infants sleeping in the prone position has been accompanied by a significant decline in the number of deaths due to SIDS.

Trans fatty acid content of human milk in Spain.

The C18 fatty acid fraction of 38 samples of mature human milk from Spanish women was analyzed using capillary gas chromatography. The average content of trans fatty acids found in these samples represented 0.95% of total fatty acids. This value is lower than the percentage found in human milk from other developed countries in which the consumption of hydrogenated fat is higher. Trans fatty acid content in human milk has been related to the types of fats and oils present in the diets of the nursing mothers. According to the results obtained in this survey, we can also conclude that the amount of trans forms in breast milk lipids is lower than the trans content found in infant formulas in Spain.

[Idiopathic varicocele in children]. / Varicocele idiopático en el niño.

The authors present their experience with ten children operated on for left-sided idiopathic varicocele over a period of seven years. The treatment was high ligature of the spermatic vein with a favorable outcome in all cases. The histology of the testes, seen in biopsy, demonstrated a variable degree of damage. For this reason the authors recommend that this operation should be done in childhood in order to avoid problems of subfertility or infertility in adult life.