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.

Weight-loss interventions and gut microbiota changes in overweight and obese patients: a systematic review.

Imbalances in the gut microbiota, the bacteria that inhabit the intestines, are central to the pathogenesis of obesity. This systematic review assesses the association between the gut microbiota and weight loss in overweight/obese adults and its potential manipulation as a target for treating obesity. This review identified 43 studies using the keywords 'overweight' or 'obesity' and 'microbiota' and related terms; among these studies, 17 used dietary interventions, 11 used bariatric surgery and 15 used microbiota manipulation. The studies differed in their methodologies as well as their intervention lengths. Restrictive diets decreased the microbiota abundance, correlated with nutrient deficiency rather than weight loss and generally reduced the butyrate producers Firmicutes, Lactobacillus sp. and Bifidobacterium sp. The impact of surgical intervention depended on the given technique and showed a similar effect on butyrate producers, in addition to increasing the presence of the Proteobacteria phylum, which is related to changes in the intestinal absorptive surface, pH and digestion time. Probiotics differed in strain and duration with diverse effects on the microbiota, and they tended to reduce body fat. Prebiotics had a bifidogenic effect and increased butyrate producers, likely due to cross-feeding interactions, contributing to the gut barrier and improving metabolic outcomes. All of the interventions under consideration had impacts on the gut microbiota, although they did not always correlate with weight loss. These results show that restrictive diets and bariatric surgery reduce microbial abundance and promote changes in microbial composition that could have long-term detrimental effects on the colon. In contrast, prebiotics might restore a healthy microbiome and reduce body fat.

When should we use partially hydrolysed formulae for frequent gastrointestinal symptoms and allergy prevention?

UNLABELLED: Experts reviewed the literature to determine whether partially whey hydrolysed formulas (HF) offer benefits in the dietary management of frequent gastrointestinal symptoms and allergy prevention. Compared with standard cow's milk-based formulas, partially whey HF confer a limited protective effect against allergic disease in high-risk infants, particularly atopic dermatitis, but not respiratory allergies. No randomised clinical trials have been published on partially whey HF in infants with colicky symptoms. The group did not find sufficient evidence to support the use of partially whey HF in regurgitation, although recent data suggest that a thickened partially whey HF may be more effective. Partially whey HF, fortified with prebiotics and/or probiotics, with high levels of sn-2 palmitate in the fat blend or without palm oil, provide some benefit in functional constipation. CONCLUSION: Overall, partially whey HF may offer a useful alternative to intact protein in the dietary management of common functional gastrointestinal symptoms.

Infants under 3 months old with cyanosis at the emergency room: could it be gastroesophageal reflux?

The aim of this study is to describe the prevalence of gastroesophageal reflux disease (GERD) in infants under 3 months old with a history of cyanotic episodes, who were examined at the emergency room of a university hospital. This descriptive study reviews reports of esophageal pH monitoring from a pediatric gastroenterology service over a period of 5 years. The following data were collected: age, sex, pediatric as well as other specialists' evaluations, and the esophageal pH monitoring reports. This study included 67 infants with a history of cyanotic episodes, with no primary cause determined by pediatrician and pediatric specialists' evaluations, who underwent esophageal pH monitoring. The infants were 6-90 days old, 41 (61.2%) of them male. Fifty infants (74.6%) had at least one esophageal pH monitoring parameter above the normal limit. ZMD index was abnormal in 32 cases (48%) and reflux index was abnormal in 31 cases (46%). When other common causes of cyanosis have been ruled out, a significant proportion of infants presenting cyanosis have abnormal pH study, suggesting the role of GERD in cyanosis. The authors highlight that reflux index is not enough to conclude whether a pH study is normal or not. The ZMD index and the presence of episodes longer than 20 minutes are also important parameters for GERD diagnosis.

Neonatal short bowel syndrome as a model of intestinal failure: physiological background for enteral feeding.

Intestinal failure (IF) is a well identified clinical condition, which is characterised by the reduction of functional gut capacity below the minimum needed for adequate digestion and absorption of nutrients for normal growth in children. Short bowel syndrome (SBS) is the leading cause of IF in neonates, infants and young children usually as a result of extensive intestinal resection during the neonatal period. Simultaneously maintaining optimal nutritional status and achieving intestinal adaptation is a clinical challenge in short bowel patients. Both growth and development of the child as well as gut adaptation should be considered synergistically as primary outcome parameters. Enteral nutrition (EN) can be introduced orally and/or by tube feeding (TF). Several controversies over nutritional treatment of children with SBS related intestinal failure remain. As reported from different centres around the world, most practices are more "experienced based" rather than "evidence based". This is partly due to the small number of patients with this condition. This review (based on a consensus) discusses the physiological principles and nutritional management, including the type of diet and route of delivery. Perspectives in optimizing intestinal adaptation and reducing the consequences of small intestinal bacterial overgrowth are also discussed.

Grey-scale and colour Doppler sonography in the evaluation of children with suspected bowel inflammation: correlation with colonoscopy and histological findings.

AIM: To evaluate the correlation of grey-scale and colour Doppler sonography with colonoscopy and histology to detect bowel inflammation in children. MATERIAL AND METHODS: The records of 72 patients with suspected bowel inflammation were reviewed retrospectively. Patients were included in the study if sonography had been performed up to 30 days before colonoscopy. Grey-scale and colour Doppler sonography were used to evaluate bowel wall thickness and vascularity for the detection of distal bowel inflammation. Findings were correlated with colonoscopy and histological findings. The sensitivity and specificity of sonographic wall thickness to detect inflammation was determined. Spearman's coefficient (rs) was used to determine the correlation of Doppler findings with colonoscopy/histology. RESULTS: Sonograms of 372 bowel segments were evaluated and results were correlated with colonoscopy and histological findings of 352 segments. The sensitivity and specificity of sonographic bowel thickness to detect inflammation in the terminal ileum and the right colon were high; in the other segments, specificity was high but sensitivity was low. The correlation of Doppler sonography with colonoscopy and histology to detect inflammation in the terminal ileum was strong (rs: 0.84; p<0.001) and in the other segments, weak to moderate; when the interval between examinations was shorter than 10 days, the correlation was stronger in all segments. Of nine patients with abnormal small bowel sonograms but normal colonoscopies, three had Crohn's disease. CONCLUSION: Sensitivity and specificity of grey-scale sonography to detect inflammation in the terminal ileum and the right colon were high, and the correlation of Doppler with colonoscopy and histology was very strong in the same segments.

[Parenteral nutrition in pediatrics] / Nutrição parenteral em pediatria.

OBJECTIVE: To present a review on parenteral nutrition in infants and children, characterizing the importance of nutrition therapy to support and recover their nutritional status. METHODS: Articles from specific journals were analyzed. Information was also obtained from the author s own experience in the area. RESULTS: Major recommendations; venous access; protein-energy composition (electrolyte, vitamins and trace elements); formulation; administration; clinical and laboratorial control; and complications were also discussed. CONCLUSIONS: Parenteral nutrition, if well-indicated, is very important for the management of several childhood diseases, allowing the maintenance and restoration of nutritional status

[Associated and prognosis in apparent life threatening events (ALTE)] / Patologias associadas e prognóstico de eventos com aparente risco de vida (ALTE).

OBJECTIVE: To verify the etiology and prognosis of ALTE in infancy and its possible relationship to Sudden Infant Death Syndrome (SIDS). METHODS: We studied a group of infants that presented ALTE episodes and were evaluated in our hospital. First we reviewed their clinical history and polysomnographies, then we sent a letter to the families with questions regarding the outcome. RESULTS: 56 patients were included. 92% had ALTE during their first 6 months and 83% in the first trimester. Symptomatic ALTE predominated (71%). The disease most frequently associated was gastroesophageal reflux, followed by neurological diseases. The follow up showed 51.5% of normal outcome, 4 children repeated ALTE, no cases of SIDS were registered. CONCLUSIONS: Our results showed that multifactorial etiologies can be associated to ALTE, and the outcome is generally related to the associated disease. We did not observe any relationship between ALTE and SIDS considering a predominantly symptomatic ALTE population.

Severe cytomegalovirus infection and immunosuppressive therapy in pediatric liver transplantation.

Twenty-two post-orthotropic liver transplant (OLT) recipients were studied to investigate the clinical, laboratory and histopathological differences between rejection and CMV infection. The mean age at the time of transplantation was five years. Nine of 22 (41%) patients developed positive CMV, CF-IgG and IgM antibody titers and cultures for CMV following surgery, and three (group 1a) developed interstitial pneumonitis. CMV specific inclusion bodies were found in lung and liver biopsies. Two patients in group 1a were treated successfully with DHPG and decreasing immunosuppressive treatment, while the third died. Clinical presentation of rejection episodes were similar in all groups. CMV infected patients (group 1) received more transfusions of blood and blood products than the non-infected patients (group 2). Rejection episodes occurred sooner and more frequently in group 1a than in group 1b (CMV infected-asymptomatic) and group 2 (non-infected). Group 2 received fewer steroid boluses as well as azathioprine and OKT 3. A percutaneous liver biopsy with routine stains helped detect CMV when inclusion bodies were seen. We conclude that culture proven CMV infection is common post-OLT. Severe CMV infection occurred more frequently in those who had received greater doses of immunosuppressive therapy for possible graft rejection. Monitoring CMV infection following OLT is absolutely necessary. After OLT, decreasing the immunosuppressives and using antiviral agents are important in the management of CMV infection.

Carcinoma bronquico: agentes determinantes na exposicao profissional. / Bronchial carcinoma: determinant agents in professional exposition

Este e um estudo de revisao dos principais agentes da exposicao profissional causadores do carcinoma bronquico. Reunem-se epidemiologicas e outros estudos clinicos que trazem importante subsidio para o entendimento da carcinogenese pulmonar. Apresentam-se nove dos elementos industriais, cujo grau de evidencia encontrado de que fossem agentes causadores do carcinoma bronquico, foi considerado suficiente. Da-se destaque especial as atividades humanas e as circunstancias que colocam os individuos em alto risco de contrair esta doenca fatal