Monitoring gestational weight gain: setting up a regional surveillance system in Italy.

BACKGROUND: In many countries, including Italy, there are few national data on pre-pregnancy Body Mass Index (BMI) and gestational weight gain (GWG), despite these being important predictors of maternal and neonatal health outcomes. This dearth of information makes it difficult to develop and monitor intervention policies to reduce the burden of disease linked to inadequate BMI status and/or GWG in pregnant women. This study describes the setting up and initial implementation of a regional surveillance system on pre-pregnancy BMI and GWG. METHODS: Between 1 January 2017 and 31 December 2018, anthropometric data were collected from all pregnant women accessing public health services in the Friuli Venezia Giulia region (Italy) for first ultrasound check (T1) and at delivery (T2). Anthropometric data collected at T1 (self-reported pre-pregnancy weight and measured weight and height) and T2 (measured weight and self-reported pre-pregnancy weight and height) were compared. RESULTS: The system was able to reach 43.8% of all the women who gave birth in the region, and provided complete data for 6400 women of the 7188 who accessed the services at T1. At the beginning of pregnancy 447 (7.0%) women were underweight, 4297 (67.1%) had normal weight, 1131 (17.7%) were overweight and 525 (8.2%) had obesity. At delivery, 2306 (36.0%) women were within the appropriate weight gain range, while for 2021 (31.6%) weight gain was insufficient and for 2073 (32.4%) excessive. Only minor differences were observed between measured and self-reported anthropometric data. CONCLUSIONS: The surveillance system offers an overview of the weight status of women during pregnancy. About 1/3 of women entered pregnancy with unsatisfactory BMI and 2/3 did not achieve the recommended weight gain. This surveillance system can be an effective tool to guide public health interventions.

Nutrient intakes in an Italian population of infants during the complementary feeding period.

OBJECTIVE: To describe the nutrient intakes of an Italian cohort of infants at 6, 9 and 12 months of age. DESIGN: Dietary data were collected using a food diary at three follow-ups (6, 9 and 12 months of age of infants). The infants' dietary data were used to estimate nutrient intakes using the Italian food composition database integrated with data from nutritional labels and the literature. The mean and standard deviation, median and interquartile range, minimum and maximum, and 5th, 25th, 75th and 95th percentiles were calculated for the daily intake of twenty-eight nutrients, with sex differences evaluated using parametric/non-parametric statistical methods. SETTING: A prospective population-based birth cohort.SubjectInfants (n 400) living in the urban area of Trieste (Italy). RESULTS: The sex distribution was fairly balanced at each follow-up. The mean daily intakes of energy and the other twenty-seven nutrients considered were greater in males at all follow-ups. In particular, a significant statistical difference was observed in higher male consumption of cholesterol at 9 months and in energy and carbohydrate intakes at 12 months (P < 0·05). The mean daily intake of proteins was greater than that recommended by the Italian Dietary Reference Values at all follow-ups. CONCLUSIONS: These preliminary results provide a useful basis for understanding the nutrient intake patterns of infants in this area of Italy during the first year of life.

Patterns of nutrients' intake at six months in the northeast of Italy: a cohort study.

BACKGROUND: Adequate complementary feeding is recognized as an important predictor of health later in life. The objective of this study was to describe the feeding practices and nutrients' intake, and their association with breastfeeding at six months of age, in a cohort of infants enrolled at birth in the maternity hospital of Trieste, Italy. METHODS: Out of 400 infants enrolled at birth, 268 (67%) had complete data gathered through a 24-hour feeding diary on three separate days at six months, and two questionnaires administered at birth and at six months. Data from feeding diaries were used to estimate nutrients' intakes using the Italian food composition database included in the software. To estimate the quantity of breastmilk, information was gathered on the frequency and length of breastfeeds. RESULTS: At six months, 70% of infants were breastfed and 94% were given complementary foods. The average daily caloric intake was higher in non-breastfed (723 Kcal) than in breastfed infants (547 Kcal, p < 0.001) due to energy provided by complementary foods (321 vs. 190 Kcal, p < 0.001) and milk (363 vs. 301 Kcal, p = 0.007). Non-breastfed infants had also higher intakes of carbohydrates, proteins, and fats. The mean intake of macronutrients was within recommended ranges in both groups, except for the higher protein intake in non-breastfed infants. These consumed significantly higher quantities of commercial baby foods than breastfed infants. CONCLUSIONS: Contrary to what is recommended, 94% of infants were not exclusively breastfed and were given complementary foods at six months. The proportion of daily energy intake from complementary foods was around 50% higher than recommended and with significant differences between breastfed and non-breastfed infants, with possible consequences for future nutrition and health.

The economic value of human milk from three cohort studies in Friuli Venezia Giulia, Italy.

BACKGROUND: The Mothers' Milk Tool, developed and launched by the Australian National University and Alive & Thrive in 2022, allows to estimate the volume and value of breastmilk using prevalence rates of breastfeeding by month of age from birth to 36 months. The objective of this study was to obtain these estimates for three cohort studies conducted in a region of Italy. METHODS: Breastfeeding data from three cohort studies carried out in 1999, 2007 and 2016, with follow-up to 12, 24 and 36 months of 842, 400 and 265 children, respectively, were entered into the downloadable version of the tool. Breastfeeding rates charts and tables with estimates of breastmilk production and value for breastfeeding of children aged 0-36 months were produced. RESULTS: The rates of initiation of breastfeeding were similar in the three cohorts, while the rates of any breastfeeding at subsequent ages increased over the years. The volumes and values of breastmilk per child increased accordingly, from around 130 L (13,000 USD) in 1999, to 200 L (20,000 USD) in 2007, to 226 L (22,600 USD) in 2016. The percentage of lost breastmilk decreased from 67.7% to 55.4% to 43.7%, respectively. Overall, the 1507 mothers of the three cohorts produced an estimated 250,000 L of breastmilk for their children aged 0-36 months. At 100 USD per litre, this would add up to around 25 million USD. CONCLUSIONS: Our study shows that the Mothers' Milk Tool can be used to estimate per child volumes and values of breastmilk produced and lost at local levels, and to provide simple indicators of the effects of breastfeeding interventions using the percentage of lost breastmilk, where datasets on rates of breastfeeding by month of age are available. The results of such studies can be used to advocate for better and adequately funded programmes for the protection, promotion and support of breastfeeding.

Specially formulated foods for treating children with moderate acute malnutrition in low- and middle-income countries.

BACKGROUND: Moderate acute malnutrition, also called moderate wasting, affects around 10% of children under five years of age in low- and middle-income countries. There are different approaches to addressing malnutrition with prepared foods in these settings; for example, providing lipid-based nutrient supplements or blended foods, either a full daily dose or in a low dose as a complement to the usual diet. There is no definitive consensus on the most effective way to treat children with moderate acute malnutrition. OBJECTIVES: To evaluate the safety and effectiveness of different types of specially formulated foods for children with moderate acute malnutrition in low- and middle-income countries, and to assess whether foods complying or not complying with specific nutritional compositions, such as the WHO technical specifications, are safe and effective. SEARCH METHODS: In October 2012, we searched CENTRAL, MEDLINE, LILACS, CINAHL, BIBLIOMAP, POPLINE, ZETOC, ICTRP, mRCT, and ClinicalTrials.gov. In August 2012, we searched Embase. We also searched the reference lists of relevant papers and contacted nutrition-related organisations and researchers in this field.     SELECTION CRITERIA: We planned to included any relevant randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before-and-after studies (CBAs), and interrupted time series (ITS) that evaluated specially formulated foods for the treatment of moderate acute malnutrition in children aged between six months and five years in low- and middle-income countries. DATA COLLECTION AND ANALYSIS: Two authors assessed trial eligibility and risk of bias, and extracted and analysed the data. We summarised dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD) with 95% confidence intervals (CI). Where appropriate, we combined data in meta-analyses using the random-effects model and assessed heterogeneity. The quality of evidence was assessed using GRADE methods. MAIN RESULTS: Eight randomised controlled trials, enrolling 10,037 children, met our inclusion criteria. Seven of the trials were conducted in Africa. In general, the included studies were at a low risk of bias. There may have been a risk of performance bias as trial participants were aware which intervention group they were in, but we did not consider this likely to have biased the outcome measurement. We were unable to assess the risk of reporting bias in half of the trials and two trials were at high risk of attrition bias. Any specially formulated food versus standard care - the provision of food increased the recovery rate by 29% (RR 1.29, 95% CI 1.20 to 1.38; 2152 children, two trials; moderate quality evidence), decreased the number dropping out by 70% (RR 0.30, 95% CI 0.22 to 0.39; 1974 children, one trial; moderate quality evidence), and improved weight-for-height (MD 0.20 z-score, 95% CI 0.03 to 0.37; 1546 children, two trials; moderate quality evidence). The reduction in mortality did not reach statistical significance (RR 0.44; 95% CI 0.14 to 1.36; 1974 children, one trial; low quality evidence). Lipid-based nutrient supplements versus any blended foods (dry food mixtures, without high lipid content), at full doses - there was no significant difference in mortality (RR 0.93, 95% CI 0.54 to 1.62; 6367 children, five trials; moderate quality evidence), progression to severe malnutrition (RR 0.88, 95% CI 0.72 to 1.07; 4537 children, three trials; high quality evidence), or the number of dropouts from the nutritional programme (RR 1.14, 95% CI 0.62 to 2.11; 5107 children, four trials; moderate quality evidence). However, lipid-based nutrient supplements significantly increased the number of children recovered (RR 1.10, 95% CI 1.04 to 1.16; 6367 children, five trials; moderate quality evidence), and decreased the number of non-recovering children (RR 0.53, 95% CI 0.40 to 0.69; 4537 children, three trials; high quality evidence). LNS also improved weight gain, weight-for-height, and mid-upper arm circumference, although for these outcomes, the improvement was modest (moderate quality evidence). One trial observed more children with vomiting in the lipid-based nutrient supplements group compared to those receiving blended food (RR 1.43, 95% CI 1.11 to 1.85; 2712 children, one trial; low quality evidence). Foods at complementary doses - no firm conclusion could be drawn on the comparisons between LNS at complementary dose and blended foods at complementary or full dose (low quality evidence). Lipid-based nutrient supplements versus specific types of blended foods - a recently developed enriched blended food (CSB++) resulted in similar outcomes to LNS (4758 children, three trials; moderate to high quality evidence). Different types of blended foods - in one trial, CSB++ did not show any significant benefit over locally made blended food, for example, Misola, in number who recovered, number who died, or weight gain (moderate to high quality evidence). Improved adequacy of home diet - no study evaluated the impact of improving adequacy of local diet, such as local foods prepared at home according to a given recipe or of home processing of local foods (soaking, germination, malting, fermentation) in order to increase their nutritional content. AUTHORS' CONCLUSIONS: In conclusion, there is moderate to high quality evidence that both lipid-based nutrient supplements and blended foods are effective in treating children with MAM. Although lipid-based nutrient supplements (LNS) led to a clinically significant benefit in the number of children recovered in comparison with blended foods, LNS did not reduce mortality, the risk of default or progression to SAM. It also induced more vomiting. Blended foods such as CSB++ may be equally effective and cheaper than LNS. Most of the research so far has focused on industrialised foods, and on short-term outcomes of MAM. There are no studies evaluating interventions to improve the quality of the home diet, an approach that should be evaluated in settings where food is available, and nutritional education and habits are the main determinants of malnutrition. There are no studies from Asia, where moderate acute malnutrition is most prevalent.

Diet and physical activity in pre-school children: a pilot project for surveillance in three regions of Italy.

OBJECTIVE: To test a surveillance system on diet and physical activity based on data gathered at well-child visits. DESIGN: Cross-sectional data collection on growth, diet, physical activity and sociodemographic variables. SETTING: Offices of 179 paediatricians in three Italian regions. SUBJECTS: 26 898 children for a total of 32 915 well-child visits at 1, 3, 5-6, 8-9, 12, 18, 24, 36 and 60-72 months of age. RESULTS: The BMI Z-score was lower than the WHO standard at 1 and 3 months but higher from 8-9 months onwards. The rates of breast-feeding at 1, 3, 5-6, 8-9 and 12 months were 88 %, 75 %, 64 %, 52 % and 32 %, respectively, with 5 % and 3 % continuing up to 24 and 36 months. Exclusive breast-feeding was 64 %, 54 % and 20 % at 1, 3 and 5-6 months, respectively; 57 % at 5 months and 85 % at 6 months were given complementary foods. Only 8 % and 10 % of children were taking five portions of fruit and vegetables daily, while 47 % and 51 % were consuming sugar-sweetened beverages at 36 and 60-72 months, respectively. At 60-72 months, less than 10 % reported at least 1 h of moderate-to-vigorous physical activity on 5-7 d/week, and 32 % watched television or played videogames for more than 2 h/d, every day. The majority of paediatricians rated the surveillance system as reliable and feasible. CONCLUSIONS: Surveillance for diet and physical activity in pre-school children, with data gathered during well-child visits, is feasible and potentially useful to plan and evaluate activities for the prevention of obesity.

Are Dietary Patterns Related to Cognitive Performance in 7-Year-Old Children? Evidence from a Birth Cohort in Friuli Venezia Giulia, Italy.

Research from different sources supports a link between nutrition and neurodevelopment, but evidence is still sparse regarding the relationship between a posteriori dietary patterns (DPs) and cognitive performance in school-aged children. Within the Northern Adriatic Cohort II, Friuli Venezia Giulia, Italy, 379 7-year-old children were cross-sectionally evaluated. Dietary patterns were identified through a principal component factor analysis based on 37 nutrients from children's 3-day dietary records. The Wechsler Intelligence Scale of Children (WISC-IV) test provided measures of cognitive performance, including the full-scale intelligence quotient (FSIQ) and single index scores. Each DP was related to FSIQ or single index scores through multiple robust linear regression models. We identified five DPs named "Dairy Products", "Plant-based Foods", "Fats", "Meat and Potatoes", and "Seafood" (63% of variance explained). After adjustment, no significant relationship was observed with the FSIQ score; positive associations were found between the "Seafood" DP and Verbal Comprehension Index or Perceptual Reasoning Index. The "Meat and Potatoes" and "Dairy Products" DPs were inversely associated with the Verbal Comprehension Index and Processing Speed Index scores, respectively. In the absence of a relation with the overall FSIQ score, single DPs might influence specific cognitive functions, including verbal and reasoning abilities, as targeted by single indexes, in the expected direction.

Clinical, anamnestic, and sociodemographic predictors of positive SARS-CoV-2 testing in children: A cross sectional study in a tertiary hospital in Italy.

OBJECTIVES: We aimed to identify clinical, anamnestic, and sociodemographic characteristics associated with a positive swab for SARS-CoV2, and to provide a predictive score to identify at risk population in children aged 2-14 years attending school and tested for clinical symptoms of COVID-19. DESIGN: Cross sectional study. SETTING: Outpatient clinic of the IRCCS Burlo Garofolo, a maternal and child health tertiary care hospital and research centre in Italy. DATA COLLECTION AND ANALYSIS: Data were collected through a predefined form, filled out by parents, and gathered information on sociodemographic characteristics, and specific symptoms, which were analysed to determine their association with a positive SARS-CoV-2 swab. The regression coefficients of the variables included in the multivariate analysis were further used in the calculation of a predictive score of the positive or negative test. RESULTS: Between September 20th and December 23rd 2020, from 1484 children included in the study, 127 (8.6%) tested positive. In the multivariate analysis, the variables retained by the model were the presence of contact with a cohabiting, non-cohabiting or unspecified symptomatic case (respectively OR 37.2, 95% CI 20.1-68.7; 5.1, 95% CI 2.7-9.6; 15.6, 95% CI 7.3-33.2); female sex (OR 1.49, 95% CI 1.0-2.3); age (6-10 years old: OR 3.2, 95% CI 1.7-6.1 p<0.001; >10 years old: OR 4.8, 95% CI 2.7-8.8 p<0.001); fever (OR 3.9, 95% CI 2.3-6.4); chills (OR 1.9, 95% CI 1.1-3.3); headache (OR 1.45, 95% CI 0.9-2.4); ageusia (OR 1.3, 95% CI 0.5-4.0); sore throat (OR 0.48, 95% CI 0.3-0.8); earache (OR 0.4, 95% CI 0.1-1.3); rhinorrhoea (OR 0.8, 95% CI 0.5-1.3); and diarrhoea (OR 0.52, 95% CI 0.2-1.1). The predictive score based on these variables generated 93% sensitivity and 99% negative predictive value. CONCLUSIONS: The timely identification of SARS-CoV2 cases among children is useful to reduce the dissemination of the disease and its related burden. The predictive score may be adopted in a public health perspective to rapidly identify at risk children.

Dietary Intake of the Italian PHIME Infant Cohort: How We Are Getting Diet Wrong from as Early as Infancy.

Unhealthy dietary habits established in early infancy may lead to under or over nutrition later in life. This paper describes the energy, nutrients and food-type intake of 18-month-old infants belonging to the Italian PHIME cohort (n = 389) and evaluates adherence to the Italian dietary reference values (DRVs). Infant dietary data were collected using 7-day dietary records. Mean energy, macro and micronutrient intakes were estimated and compared with the DRVs. The percentage contribution of 19 selected food groups to total energy and macro- and micronutrient intake was determined with the aim of establishing the main food sources. Most infants' diet shared common characteristics: poor variety, excessive intake of proteins (16.5 E% vs. 8-12 E% DRV) and saturated fatty acids (SFAs) (13.8 E% vs. <10 E% DRV), mainly derived from milk and dairy products, and low intake of total fats (33.2 E% vs. 35-40 E% DRV), polyunsaturated fatty acids (PUFAs) (3.1 E% vs. 5-10 E% DRV), vitamin D (1.1 vs. 15 µg/day DRV) and iron (4.5 vs. 8 mg/day DRV). The unbalanced distribution of macronutrients was reflected in energy intakes outside DRV ranges for more than half the infants. Public health interventions promoting healthy eating habits from early on, even from pregnancy, could yield significant short- and long-term health benefits.

Nutrient Intake during Pregnancy and Adherence to Dietary Recommendations: The Mediterranean PHIME Cohort.

Few studies provide a detailed description of dietary habits during pregnancy, despite the central role of nutrition for the health of the mother and offspring. This paper describes the dietary habits, energy and nutrient intake in pregnant women from four countries belonging to the Mediterranean PHIME cohort (Croatia, Greece, Italy and Slovenia) and evaluates their adherence to the European Food Safety Authority (EFSA) recommendations. A total of 1436 women were included in the present analysis. Maternal diet was assessed using a food frequency questionnaire (FFQ). The mean macro and micronutrient intakes were estimated and compared with the dietary reference values (DRVs). The percentage distribution of the 16 food groups in the total intake of each macronutrient was estimated. All women shared a similar diet during pregnancy; almost all the women in the four countries exceeded the DRV for sugars, and the total fat intake was above the DRV in most women in all the countries, as was the contribution of saturated fatty acids (SFAs) to the total energy intake. In all four countries, we observed an increased risk of micronutrient deficiency for iron, folate and vitamin D. Shared guidelines, implemented at both the national and European level, are essential to improve the maternal nutritional status during pregnancy.

Age-Related Trends in the Diet of An Infant's Cohort in the Northeast of Italy from Six to Twelve Months of Age.

Complementary feeding is recognized as an important predictor of health later in life and is likely to affect the development of food preferences. This paper describes age-related trends in terms of energy, nutrients intake and dietary habits of an Italian infant sub cohort (n = 152), enrolled in Trieste. Infant dietary data, collected using a food diary at 6, 9 and 12 months of age, were used to estimate energy and nutrients intake using the Italian food composition database. Age-related trends were calculated using Page's trend test. An increasing age-trend was observed in the percentages of contribution of macronutrients to total energy intake, with the exception of total lipids, which instead decreased over time. Most of the infants shared a low varied diet especially with regards to protein intake sources, represented mainly by dairy and meat products rather than pulses and fish. This could also account for the low intake of essential fatty acids (ω3) that play an important role in infant neurodevelopment. Moreover, non-commercial baby foods contributed more in terms of quantity, energy and macronutrients intake, compared with commercial products. Healthy eating habits should be encouraged during the first year of life, promoting a varied and well balanced diet at family level.

Introduction of Complementary Foods in a Cohort of Infants in Northeast Italy: Do Parents Comply with WHO Recommendations?

Timing and type of complementary food in infancy affect nutritional status and health later in life. The objective of this paper was to assess complementary feeding practices, looking at timing, type, and compliance with World Health Organization (WHO) recommendations. Data were obtained from a birth cohort of 400 infants, enrolled in Trieste (Italy) between July 2007 and July 2008 and followed up for three years, using a "food introduction timing table". Five WHO recommendations standards were used to assess parental compliance and associated factors. Thirty seven percent of mothers returned the completed "timing table" up until the child was three years of age. Eighty six percent of infants were already receiving complementary foods at six months. The first food type to be introduced was fresh fruit (170 days from birth, median). Overall, infants shared a very similar diet, which was different from the family diet and characterized by delayed introduction of certain food types. Five percent of parents complied with either all five or only one of the WHO recommendations, 34% with three, and 35% with four. The parents' partial compliance with WHO recommendations is probably due to conflicting information received from different sources. This advocates for national evidence-based guidelines, supported and promoted by health professionals.

Advertisements of follow-on formula and their perception by pregnant women and mothers in Italy.

OBJECTIVE: To assess how follow-on formula milks for infants aged 6-12 months are presented to and understood by mothers. DESIGN: A quantitative and qualitative cross-sectional study including (1) an analysis of advertisements in three magazines for parents; (2) in-depth semistructured qualitative interviews to pregnant women on their perception of two advertisements for follow-on formula and (3) self-administered questionnaires for mothers to explore their exposure to and perception of formula advertisements. PARTICIPANTS: Eighty pregnant women 32-36 weeks of gestation with no previous children and 562 mothers of children <3 years old. SETTING: Maternal and child health centres in eight cities of Italy. RESULTS: Advertisements of formula (n=89) represented about 7% of all advertisements in the three magazines, the majority (58%) being for follow-on formula. Advertisements were parent-oriented, aimed at helping parents solve health problems of their babies or at eliciting good feelings, or both. The qualitative interviews to pregnant women showed inability to define the advertised products at first glance due to the ambiguity of the numeral 2 and the presumed age of the portrayed baby; this inability did not disappear after carefully viewing the advertisements and reading the text. When asked in the self-administered questionnaires whether they had ever come across advertisements of infant formula, 81% of mothers reported that they had, despite the legal inexistence of such advertisements, and 65% thought that it was for a product to be used from birth. CONCLUSIONS: Advertisements of follow-on formula are perceived by pregnant women and mothers as promoting infant formula.

Breastfeeding to 24 months of age in the northeast of Italy: a cohort study.

AIM: This study assessed the prevalence and duration of breastfeeding up to 24 months and the associated socioeconomic determinants in a birth cohort of children. METHODS: Four hundred infants born in a hospital in the north east of Italy were enrolled at birth and followed up for 36 months. Data on infant feeding were gathered through a feeding diary compiled at fixed intervals. Data were also gathered on type of delivery and weight, length, and health status at birth, as well as on selected socioeconomic indicators of the mothers. A multivariate logistic regression analysis was used to determine any association that exclusivity and duration of breastfeeding may have with selected socioeconomic variables and with health conditions of the infants at birth. RESULTS: Ninety-eight percent of mothers initiated breastfeeding, 69% of them exclusively. This rate, however, had declined to 6% by 6 months. There was a remarkable endurance of breastfeeding at 24 months (12%). The variables significantly associated with exclusive breastfeeding at 3 months and any form of breastfeeding at 12 months are mother's age (p=0.007 at 3 months, p=0.026 at 12 months) and postdischarge hospital admission (p=0.029 at 3 months). CONCLUSIONS: In this population, breastfeeding rates are higher than previously reported, but lower than recommended, especially as far as exclusivity is concerned. Full implementation of the World Health Organization-UNICEF Baby Friendly Initiatives in hospitals and communities is needed to improve them further. Monitoring systems should include the collection of data on breastfeeding beyond 12 months of age.