ARA or no ARA in infant formulae, that is the question.

Recently, the European Commission issued a Delegated Regulation updating the compositional and information requirements for infant and follow-on formulae that are to be applied at the latest in February 2021. This new regulation changes the status of docosahexaenoic acid (DHA) from an optional ingredient to a mandatory nutrient in these formulae at levels between 20 and 50mg/100kcal (0.5-1% of fatty acids). By contrast, arachidonic acid (ARA) becomes an optional nutrient. Following publication of the new regulation, global scientific experts have expressed concerns regarding the potential health risks of new infant formulae containing only DHA, especially at levels higher than those in breast milk and infant formulae marketed to date. Both DHA and ARA play a crucial role in infant development. First, breast milk, the gold standard for infant feeding, contains both DHA and ARA. Second, during development, the conversion of linoleic acid into ARA through desaturation steps is not sufficient to meet nutritional needs, especially in carriers of newly identified genetic variants in fatty acid desaturases, which weaken the biosynthetic production of ARA. Third, circulating levels of DHA and ARA in breastfed infants can only be matched with the addition of both fatty acids to formulae. And fourth, most studies performed to date have demonstrated that important physiological and developmental endpoints are sensitive to the ratio of dietary ARA:DHA. The precautionary principle applies when implementing the new EU regulation for infant and follow-on formulae. As a consequence, given the vulnerability of developing infants as well as the absence of conclusive evidence that formulae with at least 20mg DHA/100kcal, but no ARA, are safe and suitable to support the growth and development of infants similar to their breastfed peers, it remains necessary to still market formulas containing both ARA and DHA until proved otherwise.

Assessment of the severity of infant crying and its impact on parents: Development and validation of the ColiQ Questionnaire in France.

OBJECTIVES: The purpose of this study was to develop and validate a questionnaire that comprehensively assesses symptoms and severity of crying, symptoms suggesting infant functional gastrointestinal discomfort, and its impact on parents' quality of life: the Infant Colic Questionnaire (ColiQ©). For the first time, parents had access to a web application to follow their infants' evolving symptoms with a daily questionnaire. METHODS: The ColiQ was developed with a board of clinical experts (physicians and psychologists) based on extensive parent input. A longitudinal, observational study was conducted in France for 3 months. ColiQ assessments were collected online at six different time points. Psychometric testing demonstrated that ColiQ has acceptable psychometric properties (reliability, internal consistency, construct validity, and responsiveness). RESULTS: The ColiQ is a 16-question instrument developed in French including ten questions describing symptoms (Infant score) and six questions describing impacts (Parent score). The ColiQ demonstrated good test-retest reliability (ICC >0.70), internal consistency for both the Symptom and Impact subscale scores (Cronbach's α >0.70), and construct validity. Responsiveness was good; the ColiQ was able to detect significant improvement in the target population as early as 1 month (p<0.05). The global ColiQ score discriminated between severity levels (mild, medium, severe). CONCLUSIONS: The ColiQ was developed with input from parents and healthcare professionals and has shown validity, reliably, and responsiveness to change. Parents can use the web application to follow how their infants' symptoms evolve. The ColiQ can help parents quantify and verbalize their concerns during consultations, and provides an opportunity to facilitate conversations between the physician and parents.

Treatments for pediatric achalasia: Heller myotomy or pneumatic dilatation?

AIM: The treatment of achalasia consists of reducing distal esophageal obstruction by either Heller myotomy surgery or endoscopic pneumatic dilatation. The aim of the present study was to evaluate the short- and middle-term results of these procedures in children. METHODOLOGY: For technical reasons, children under six years old (n=8) were treated by surgery only, whereas patients over six years old (n=14) were treated by either Heller myotomy or pneumatic dilatation. RESULTS: Of the children aged under six years, 75% were symptom-free at six months and 83% at 24 months of follow-up. Of the patients aged over six years, complete remission was achieved by Heller myotomy in 44.5% vs. 55.5% by pneumatic dilatation after six months, and in 40% vs. 65%, respectively, after 24 months. Both pneumatic dilatation and Heller myotomy showed significant rates of failure. CONCLUSION: These results suggest that pneumatic dilatation may be considered a primary treatment in children over six years old. Also, where necessary, Heller myotomy and pneumatic dilatation may be used as complementary treatments.

[Ingestion of foreign bodies in children. Recommendations of the French-Speaking Group of Pediatric Hepatology, Gastroenterology and Nutrition]. / Ingestion de corps étrangers chez l'enfant. Recommandations du Groupe francophone d'hépatologie, gastroentérologie et nutrition pédiatriques.

Ingestion of foreign bodies is a common pediatric problem. The majority of ingested foreign bodies pass spontaneously. Management of foreign body ingestions varies based upon the object ingested, its location, and the patient's age and past history. Esophageal foreign bodies should be urgently removed because of their potential to cause complications. Ingested batteries that lodge in the esophagus, sharp or pointed foreign bodies in the esophageal or gastric tract, and ingestion of multiple magnets all require urgent endoscopic removal. Flexible endoscopy is the therapeutic modality of choice for most patients. The use of devices such as a latex protector hood or an overtube may facilitate safer extraction of sharp objects.

[Hemorrhagic ascites revealing duodenal duplication]. / Une ascite hémorragique révélant une duplication duodénale.

Duodenal duplication is a rare congenital disorder of the gastrointestinal tract. The presentation is highly variable. We report a case of duodenal duplication presenting with hemorrhagic ascites in a 3-month-old girl. The diagnosis of duodenal duplication can be made preoperatively by resonance magnetic imaging. Surgical resection of the duplication was performed. Microscopic examination of the specimen confirmed the duodenal duplication. To our knowledge, this is the 1st reported case of hemorrhagic ascites caused by duodenal duplication and demonstrated by resonance magnetic imaging.

Vegan diet in children and adolescents. Recommendations from the French-speaking Pediatric Hepatology, Gastroenterology and Nutrition Group (GFHGNP).

The current craze for vegan diets has an effect on the pediatric population. This type of diet, which does not provide all the micronutrient requirements, exposes children to nutritional deficiencies. These can have serious consequences, especially when this diet is introduced at an early age, a period of significant growth and neurological development. Even if deficiencies have less impact on older children and adolescents, they are not uncommon and consequently should also be prevented. Regular dietary monitoring is essential, vitamin B12 and vitamin D supplementation is always necessary, while iron, calcium, docosahexaenoic acid, and zinc should be supplemented on a case-by-case basis.

Family history of atopy in infants with cow's milk protein allergy: A French population-based study.

OBJECTIVES: This French multicenter, cross-sectional, observational study aimed to describe the family history of atopy in infants with cow's milk protein allergy (CMPA), and the related diagnostic approaches used by specialists in a real-life ambulatory setting. PATIENTS AND METHODS: In total, 1674 infants with suspected CMPA [median age 4.5 months (range: 0.1-18.0), males 54%] were enrolled in the study by 466 private physicians (pediatricians: 97%). Family history of atopy was defined as a known history of atopy in at least one first- (father, mother, and/or sibling) and/or second-degree relative (grandparents, uncles, and aunts), as reported by parents to physicians. RESULTS: Atopy in a first-degree relative was more common among infants with documented or high probability of CMPA (in 84% and 80% of cases, respectively, vs. the other subgroups, P=0.005). Most infants experienced digestive (92%) and skin (61%) symptoms suggestive of CMPA. Delayed reactions were reported in 64% of infants. According to a post-classification based on the results of previous diagnostic tests and procedures, 1133 infants (68%) had highly probable (52%) or documented CMPA (16%). In these infants, a history of atopy was reported in first- and/or second-degree relative(s) in 86% of cases (81% in first-degree relatives). Whatever the family history of atopy, the characteristics of the infants were similar, except for fewer pets in the case of negative family atopy (14% vs. 25%, P<0.001). Atopy in a parent was more frequent in infants who presented with the first signs suggestive of CMPA within the first 6 months of life vs. those with later first symptoms (75% vs. 65%, P=0.063). CONCLUSION: This French study confirms the high rate of family history of atopy in first-degree relatives of infants with probable or documented CMPA.

[Rotavirus: an ubiquitous infection?]. / Rotavirus: une infection ubiquitaire?

Rotavirus is the most frequent virus found in childhood gastroenteritis. A rotavirus viremia is observed in 19 to 63 % of cases, for three days at the beginning of infection. Then, rotavirus can reach several organs as liver (hepatitis in 1/3 of case), nervous central system (2 % of encephalitis could be linked to rotavirus), or more infrequently mesenteric lymph nodes, lung or heart. However, the link between rotavirus and systemic manifestations has not been well established. Further studies are necessary to confirm the role of rotavirus in these organ's lesions.

[Medication in infectious acute diarrhea in children]. / Traitement médicamenteux des diarrhées aiguëis du nourrisson et de l'enfant.

Acute infectious diarrhea in children remain still a frequent cause of morbidity. 50 % of them are due to rotavirus. Oral rehydration therapy and early realimentation have drastically reduced their mortality and morbidity. Beside oral or eventually IV rehydration therapy no medication has proven its efficacy based on the main HMO criteria (reduction of over 30 % of the stool output) except racecadotril and loperamide which is contre-indicated for the last one in children less than 2 years old. Other medications such as silicates or some probiotics have shown efficacy on diarrhea duration or stool consistency but not on stool output. They have so no formal indication in infectious diarrhea and should be considered as "comfort" treatment. Antibiotics, beside their indication in shigella, cholera and amibiasis could be used in invasive diarrhea in some debilating conditions or infants less than 3 months.

[When and how should small-bowel capsule endoscopy be used in children?] / Quand et comment utiliser la vidéocapsule endoscopique de l'intestin grêle chez l'enfant ?

Small-bowel capsule endoscopy (CE) has recently been used in children. During the past few years, an intense research activity has defined the advantages and limitations of CE. Its uses have been established in several small-bowel pathologies such as obvious or obscure digestive bleeding, Crohn disease, and hereditary polyposis. Although the absence of biopsy reduces the specificity of CE findings, small-bowel exploration using CE achieves better accuracy in detecting lesions than most radiological examinations. In children, swallowing problems and the risk of retention due to stenosis are the main concerns when using CE: these problems can be solved using endoscopic delivery of the capsule and luminal diameter calibration, respectively. This review focuses on the evidence making CE indispensable to small-bowel exploration.

Guidelines for proton pump inhibitor prescriptions in paediatric intensive care unit.

Background Stress ulcer prophylaxis (SUP) is recommended in some situations to prevent upper gastrointestinal bleeding and is a component of standard care for patients admitted to the intensive care unit (ICU). Proton pump inhibitors (PPIs), already among the most widely prescribed drug classes, are being increasingly used. Objective To describe PPI prescribing patterns and their changes after the dissemination of guidelines. Setting Paediatric ICU (PICU), Robert-Debré Teaching Hospital, Paris, France, which admits about 800 patients annually, from full-term neonates to 18-year-olds. Method Prospective observational study with two 6-week observation periods (July-August and September-October, 2013), before and after dissemination in the PICU of PPI prescribing guidelines. Main outcome measure Changes in PPI prescribing patterns (prevalence, dosage, and indication) after the guidelines. Results The number of patients admitted to the PICU was 77 (mean age 4.6 years [range 1 day-18 years]) before and 70 (mean age 3.8 years [range 1 day-17 years]) after the guidelines. During both periods, SUP was the most common reason for PPI prescribing. The proportion of patients prescribed PPIs dropped significantly, from 51% before the guidelines to 30% after the guidelines (p < 0.001). Mean daily dosage also decreased significantly, from 1.5 mg/kg/(range 0.5-4.4) to 1.1 mg/kg (range 0.7-1.8) (p < 0.002). None of the patients experienced upper gastrointestinal bleeding during either period. Conclusion Off-label PPI prescribing for SUP was common in our PICU. The introduction of guidelines was associated with a significant decrease in PPI use and dosage. This study confirms that guidelines can change PPI prescribings patterns in paediatric practice.

[Gastroesophageal reflux and sleep position of infants. A survey conducted in France by 493 pediatricians]. / Reflux gastro-œsophagien et position de couchage des nourrissons. Enquête de pratique menée en France auprès de 493 pédiatres.

BACKGROUND AND AIMS: The supine sleeping position with the head higher than the legs has no impact on regurgitations in infants. Inclined ventral decubitus decreases regurgitations but is associated with an increased risk of sudden infant death syndrome (SIDS). The LUNE study aimed to evaluate the impact of regurgitations on the choice of sleeping position by pediatricians and parents. METHODS: Cross-sectional case-control study (ratio 1:1) conducted in France in 2013. A representative sample of pediatricians recruited 3-week to 4-month-old breast- or formula-fed infants. Cases and controls were defined by the presence or absence of regurgitations. Collected data included Vandenplas codification for regurgitations (VD, range 0-6), associated symptoms, and variations in sleeping position since maternity hospital discharge. RESULTS: A total of 1347 cases and 1346 controls were recruited by 493 pediatricians. Regurgitations were evaluated at VD1 (minor, 22 % of cases), VD2 (mild, 47 % of cases), or VD≥3 (moderate to severe, 31 % of cases). At the maternity hospital, the supine position was recommended to 96 % of parents for SIDS prevention. Since discharge, parents asked questions about the relationship between sleeping position and regurgitations (79 % of infants with GER versus 45 % of controls). The sleeping position was modified at least once since maternity discharge (42 % of infants with GER versus 35 % of controls). At inclusion, 86 % of infants with GER and 86 % of controls were sleeping on their back. Fifty-one percent of infants with GER and 28 % of controls slept in an inclined position. Pediatricians repeated the prescription of dorsal decubitus for 91 % of infants with GER and recommended an inclined position in 70 %. CONCLUSIONS: Regurgitations had no impact on supine sleeping position. The inclined supine sleeping position was more frequent in infants with regurgitations with pediatricians' assent, which is not in agreement with evidence-based medicine.

Interaction of monensin and sulfadimethoxine in broilers, as mediated by hepatic microsomal cytochrome P-450 monooxygenases.

The influence of monensin + sulfadimethoxine on cytochrome P-450 monooxygenase activity in broilers, and the possible consequences of modification of this system, including changes in blood levels of sulfadimethoxine, influence on the duration of xylazine-ketamine anesthesia, total antioxidant status and superoxide dismutase activity were studied. The results indicate that the combination of monensin + sulfadimethoxine gave a short-term inhibition of microsomal cytochrome P-450 monooxygenase activity but apparently did not influence the metabolism of other (exogenic) substances (ketamine, xylazine), and did not change the state of antioxidant systems or the relative liver weight. There was a rise in blood sulfadimethoxine levels.

The inhibitory effects of the fluoroquinolone antimicrobials norfloxacin and enrofloxacin on hepatic microsomal cytochrome P-450 monooxygenases in broiler chickens.

The fluoroquinolone antimicrobials norfloxacin and enrofloxacin were found to inhibit hepatic microsomal cytochrome P-450 monooxygenases in the livers of broiler chickens using dosages as given in commercial flocks. Norfloxacin inhibited the process of N-demethylation of aminopyrine to a greater degree, while enrofloxacin more markedly inhibited hydroxylation of aniline.

Relationship between broiler chicken haematocrit-selected parents and their progeny, with regard to haematocrit, mortality from ascites and bodyweight.

A previous work of this group demonstrated that the relative haematocrit value of broilers is inherited and may serve as an indicator to susceptibility to the ascites syndrome in cold-stressed broilers. In this study, a full-pedigreed population was produced from male and female grandparent breeding stock that was selected by haematocrit and by normal selection parameters. Matings were made between low (L), medium (M) and high (H) haematocrit parents: L x L, M x M, and H x H. In their progeny, both before and after cold exposure, there was a statistically linear relationship between actual haematocrit and their H, M and L grouping (P<0.0001); heritability of the haematocrit was high (0.46-0.81). Both the low haematocrit parent and progeny groups showed an increased bodyweight. Exposure of the progeny from all the parental groups to an ascites-predisposing cold environment caused similar losses from ascites in the progeny of all three groups. Although this finding was not the same as in the previous trial where the H haematocrit group was associated with high ascites mortality, it is hypothesized that other factors, such as arterial blood saturation with oxygen, interacted in these birds at genetic or environmental levels.

Interaction of fluoroquinolones and certain ionophores in broilers: effect on blood levels and hepatic cytochrome p450 monooxygenase activity.

The concomitant administration to broilers of ionophore coccidiostats and certain chemotherapeutic agents may cause deleterious interactions, with toxicosis and death as possible sequelae. In this study, co-administration of the ionophore monensin was not shown to alter blood levels of enrofloxacin or norfloxacin. In addition, exposure to lasalocid was not shown to change blood levels of enrofloxacin. However, norfloxacin + lasalocid co-administration induced aminopyrine N-demethylase (AD) activity by day 5 after the last administration of norfloxacin, and induced a rise of norfloxacin levels in the blood. This rise of blood norfloxacin levels after co-administration of norfloxacin + lasalocid implies that lower levels of norfloxacin could be administered in birds also receiving lasalocid.

Lead toxicosis in a captive bottlenose dolphin (Tursiops truncatus) consequent to ingestion of air gun pellets.

A captive bottlenose dolphin (Tursiops truncatus) in a dolphinarium in Tel Aviv, Israel, had signs of anorexia, weight loss and a reluctance to train over a 4-week period in June 1995 and died shortly thereafter. On necropsy, it had an enlarged, yellow discolored liver, and about 55 air gun pellets in the second stomach. The pellets were composed of 40% lead. Samples of liver and kidney cortex contained 3.6 and 4.2 micrograms/g lead, respectively. There was hemosiderosis in the liver and kidneys, status spongiosus in the brain, and vacuolization in the optic nerve; acid-fast intranuclear inclusion bodies were seen in the kidneys. We propose that chronic lead toxicosis had been induced after the gradual dissolution of the lead-based pellets in the acid environment of the stomach.

Hematocrit values and mortality from ascites in cold-stressed broilers from parents selected by hematocrit.

A hypothesis that the relative hematocrit value of broilers is inherited and can serve as an indicator of partial resistance to the ascites syndrome in cold-stressed broilers was shown to be valid in a field trial. Hematocrits were determined for male and female grandparent breeding stocks. Matings were then made between low (LL), low-medium (LM), medium-high (MH), and high (HH) hematocrit parents: LL x LL, LM x LM, MH x MH, and HH x HH. The progeny of HH parents had higher hematocrit values than the progeny of lower hematocrit parents (P < 0.0001). Exposure of the progeny from all the parental groups to an ascites-predisposing cold environment caused higher losses from ascites in the progeny of the HH parents (P < 0.0001). The progeny of LH parents had an increased mortality from causes other than ascites (P < 0.0001). This work suggests that elimination of birds with HH in broiler breeding programs may be desirable where cold-induced ascites is an important problem.

Comparative effects of added sodium chloride, ammonium chloride, or potassium bicarbonate in the drinking water of broilers, and feed restriction, on the development of the ascites syndrome.

A hypothesis that the ionic composition of drinking water might affect development of the ascites syndrome in broilers was investigated in two trials. The first trial comprised four groups of 650 male chicks. A control treatment was normal tap water and the other three treatments comprised the addition to the tap water of 1,000 mg/L sodium as NaCl, 5,000 mg/L NH4Cl, or 5,000 mg/L KHCO3, supplied from age 2 to 47 d. At Day 28, equally sized subsets of these groups were moved to individual cages, where they received a severe exposure to ambient cold. The development of the ascites syndrome was monitored by measurements of hematocrit and arterial blood oxygen saturation (PaO2) by oximetry, body weight, and examination of dead birds for cause of death. Mortality from ascites in cold-exposed birds from Days 28 to 47 was 28, 48, 40, and 16% in the tap water, NaCl, NH4Cl, and KHCO3 groups, respectively; only the NaCl mortality was significantly different from the tap water mortality. The KHCO3 treatment increased PaO2 (compared with tap water treatment) at Day 28 by 5.5% and at Day 35 by 10.5%, but not at Day 42. The KHCO3 caused a reduction in body weight, which was 13% less than the tap water group at Day 42, probably due to a chronic toxicity. The second trial specifically examined the same parameters with lower water levels of KHCO3 (3,000 and 1,000 mg/L), in comparison to a 10% feed restriction protocol, in order to clarify whether the increased PaO2 was due to a specific effect of the KHCO3 or was a metabolic manifestation of a reduced growth rate. The 3,000 mg/L KHCO3 treatment had no effect on PaO2, but the 1,000 mg/L treatment augmented PaO2 by 5.3% at Day 35 (but not at Days 28 or 42), without reducing the final body weight. The feed restriction group showed an elevated PaO2 of 5.4% at Day 35 (but not at Days 28 or 42), with no reduction in the final body weight. The inclusion of 1,000 mg/L of KHCO3 into the drinking water of broilers or a temporary 10% feed restriction may be means to augment PaO2.