Correlates of Plasma Citrulline, a Potential Marker of Enterocyte Mass, among Children with Stunting: A Cross-Sectional Study in Uganda.

BACKGROUND: Environmental enteric dysfunction (EED) is associated with stunting. Citrulline, produced in mature enterocytes, may be a valuable biomarker of small intestinal enterocyte mass in the context of EED. OBJECTIVES: We aimed to explore the correlates of plasma citrulline (p-cit) in children with stunting. METHODS: In a cross-sectional study using baseline data from the community-based MAGNUS (milk affecting growth, cognition and the gut in child stunting) trial (ISRCTN13093195), we explored potential correlates of p-cit in Ugandan children with stunting aged 12-59 mo. Using linear regression in univariate and multivariate models, we explored associations with socioeconomics, diet, micronutrient status, and water, sanitation, and hygiene characteristics. The influence of covariates age, fasting, and systemic inflammation were also explored. RESULTS: In 750 children, the mean ± standard deviation age was 32.0 ± 11.7 mo, and height-for-age z-score was -3.02 ± 0.74. P-cit, available for 730 children, differed according to time fasted and was 20.7 ± 8.9, 22.3 ± 10.6 and 24.2 ± 13.1 µmol/L if fasted <2, 2-5 and >5 h, respectively. Positive correlates of p-cit were age [0.07; 95% confidence interval (CI): 0.001, 0.15 µmol/L] and log10 serum insulin-like growth factor-1 (8.88; 95% CI: 5.09, 12.67 µmol/L). With adjustment for systemic inflammation, the association with serum insulin-like growth factor-1 reduced (4.98; 95% CI: 0.94, 9.03 µmol/L). Negative correlates of p-cit included food insecurity, wet season (-3.12; 95% CI: -4.97, -1.26 µmol/L), serum C-reactive protein (-0.15; 95% CI: -0.20, -0.10 µmol/L), serum α1-acid glycoprotein (-5.34; 95% CI: -6.98, -3.70 µmol/L) and anemia (-1.95; 95% CI: -3.72, -0.18 µmol/L). Among the negatively correlated water, sanitation, and hygiene characteristics was lack of soap for handwashing (-2.53; 95% CI: -4.82, -0.25 µmol/L). Many associations attenuated with adjustment for inflammation. CONCLUSIONS: Many of the correlates of p-cit are characteristic of populations with a high EED prevalence. Systemic inflammation is strongly associated with p-cit and is implicated in EED and stunting. Adjustment for systemic inflammation attenuates many associations, reflecting either confounding, mediation, or both. This study highlights the complex interplay between p-cit and systemic inflammation.

Correlates of body composition in children with stunting: A cross-sectional study in Uganda.

BACKGROUND: Development of body composition (BC) may be disrupted in children with stunting. Such disruption may affect later risk of excess adiposity and metabolic health, yet few studies have investigated correlates of BC in children with stunting. OBJECTIVE: We aimed to investigate nutritional status, infection and inflammation, breastfeeding behaviors and other factors as correlates of BC in children with stunting. METHODS: Among Ugandan children with a height-for-age z-score <-2, BC was estimated using bioelectrical impedance analysis and compared to UK references. We used multiple linear regression analysis to identify correlates of fat mass (FM), fat-free mass (FFM), FM-index (FMI), and FFM-index (FFMI) and height, adjusting for sex and age. RESULTS: In 750 children aged 1-5 years, FMI was 0.46 [95%CI:0.38,0.54] and FFMI 0.18 [95%CI:0.11,0.26] z-scores lower than UK references. Elevated serum α1-acid glycoprotein was associated with 1.14 [0.76,1.52] cm lower height, 0.50 [0.35,0.65] kg/m2 less FFMI, and 0.48 [0.31, 0.66] kg/m2 greater FMI. Similar, weaker, associations for elevated serum C-reactive protein were detected. A positive malaria rapid test was associated with 0.64 [0.25,1.02] cm shorter height, but 0.36 [0.18,0.54] kg/m2 greater FMI. Anemia (according to hemoglobin) was associated with 0.20 [0.07,0.33] kg less FFM in proportion with shorter height. Longer breastfeeding duration was associated with 0.03 [0.02, 0.04] kg greater FFM per month, in proportion to greater height. CONCLUSION: These children exhibited deficits in FM and FFM, proportionally to their stunted height, compared to UK references. Systemic inflammation correlated inversely with linear growth and fat-free but positively with fatness, making it a possible target for intervention where fat-free tissue accretion is desirable. Longer breastfeeding may offer protection to lean linear growth but findings for micronutrients were less clear. Longitudinal studies are warranted to support these findings. The study was registered at www.isrctn.com (Ref. ISRCTN13093195).

Effect of milk protein and whey permeate in large quantity lipid-based nutrient supplement on linear growth and body composition among stunted children: A randomized 2 × 2 factorial trial in Uganda.

BACKGROUND: Despite possible benefits for growth, milk is costly to include in foods for undernourished children. Furthermore, the relative effects of different milk components, milk protein (MP), and whey permeate (WP) are unclear. We aimed to assess the effects of MP and WP in lipid-based nutrient supplement (LNS), and of LNS itself, on linear growth and body composition among stunted children. METHODS AND FINDINGS: We performed a randomized, double-blind, 2 × 2 factorial trial among 12 to 59 months old stunted children in Uganda. Children were randomized to 4 formulations of LNS with MP or soy protein isolate and WP or maltodextrin (100 g/day for 12 weeks) or no supplementation. Investigators and outcome assessors were blinded; however, participants were only blinded to the ingredients in LNS. Data were analyzed based on intention-to-treat (ITT) using linear mixed-effects models adjusted for age, sex, season, and site. Primary outcomes were change in height and knee-heel length, and secondary outcomes included body composition by bioimpedance analysis (ISRCTN13093195). Between February and September 2020, we enrolled 750 children with a median age of 30 (interquartile range 23 to 41) months, with mean (± standard deviation) height-for-age z-score (HAZ) -3.02 ± 0.74 and 12.7% (95) were breastfed. The 750 children were randomized to LNS (n = 600) with or without MP (n = 299 versus n = 301) and WP (n = 301 versus n = 299), or no supplementation (n = 150); 736 (98.1%), evenly distributed between groups, completed 12-week follow-up. Eleven serious adverse events occurred in 10 (1.3%) children, mainly hospitalization with malaria and anemia, all deemed unrelated to the intervention. Unsupplemented children had 0.06 (95% confidence interval, CI [0.02, 0.10]; p = 0.015) decline in HAZ, accompanied by 0.29 (95% CI [0.20, 0.39]; p < 0.001) kg/m2 increase in fat mass index (FMI), but 0.06 (95% CI [-0.002; 0.12]; p = 0.057) kg/m2 decline in fat-free mass index (FFMI). There were no interactions between MP and WP. The main effects of MP were 0.03 (95% CI [-0.10, 0.16]; p = 0.662) cm in height and 0.2 (95% CI [-0.3, 0.7]; p = 0.389) mm in knee-heel length. The main effects of WP were -0.08 (95% CI [-0.21, 0.05]; p = 220) cm and -0.2 (95% CI [-0.7; 0.3]; p = 403) mm, respectively. Interactions were found between WP and breastfeeding with respect to linear growth (p < 0.02), due to positive effects among breastfed and negative effects among non-breastfed children. Overall, LNS resulted in 0.56 (95% CI [0.42, 0.70]; p < 0.001) cm height increase, corresponding to 0.17 (95% CI [0.13, 0.21]; p < 0.001) HAZ increase, and 0.21 (95% CI [0.14, 0.28]; p < 0.001) kg weight increase, of which 76.5% (95% CI [61.9; 91.1]) was fat-free mass. Using height-adjusted indicators, LNS increased FFMI (0.07 kg/m2, 95% CI [0.0001; 0.13]; p = 0.049), but not FMI (0.01 kg/m2, 95% CI [-0.10, 0.12]; p = 0.800). Main limitations were lack of blinding of caregivers and short study duration. CONCLUSIONS: Adding dairy to LNS has no additional effects on linear growth or body composition in stunted children aged 12 to 59 months. However, supplementation with LNS, irrespective of milk, supports linear catch-up growth and accretion of fat-free mass, but not fat mass. If left untreated, children already on a stunting trajectory gain fat at the expense of fat-free mass, thus nutrition programs to treat such children should be considered. TRIAL REGISTRATION: ISRCTN13093195.

Hyperlipidemia in children and adolescents with acute lymphoblastic leukemia: A systematic review and meta-analysis.

BACKGROUND: The established association between acute lymphoblastic leukemia (ALL) and hyperlipidemia has, in some studies, been linked to toxicities such as pancreatitis, thrombosis, and osteonecrosis. However, a systematic review investigating the incidence, management, and clinical implications of hyperlipidemia during childhood ALL treatment is lacking. OBJECTIVES: Systematically assess the incidence of hyperlipidemia during ALL treatment, explore associations with risk factors and severe toxicities (osteonecrosis, thrombosis, and pancreatitis), and review prevalent management strategies. METHODS: A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Data synthesis was descriptive, and a meta-analysis of hypertriglyceridemia and risk of severe toxicities was performed. RESULTS: We included 13 studies with 3,425 patients. Hyperlipidemia incidence varied widely (6.7%-85%) but with inconsistent definitions and screening strategies across studies. Evidence regarding risk factors was conflicting, but age (> 10 years) and treatment with asparaginase and glucocorticosteroids seem to be associated with hyperlipidemia. Hypertriglyceridemia (grade 3/4) increased the risk for osteonecrosis (odds ratio (OR): 4.27, 95% confidence interval (CI): 2.77-6.61). No association could be established for pancreatitis (OR: 1.60, 95% CI: 0.53-4.82) or thrombosis (OR: 2.45, 95% CI: 0.86-7.01), but larger studies are needed to confirm this. CONCLUSION: The overall evidence of this systematic review is limited by the small number of studies and risk of bias. Our review suggests that hypertriglyceridemia increases the risk for osteonecrosis. However, larger studies are needed to explore the clinical implications of hyperlipidemia and randomized trials investigating hyperlipidemia management and its impact on severe toxicities.

Vitamin D status of 3-year-old children in Denmark: determinants and associations with bone mineralisation and blood lipids.

PURPOSE: Low vitamin D status is a global problem and has been associated with reduced skeletal and cardiometabolic health. However, evidence in young children is lacking. We, therefore, aimed to characterise vitamin D status in toddlers, identify its determinants, and explore if vitamin D status was associated with bone mineralisation and lipid profile. METHODS: We used cross-sectional data from 3-year-old children (n = 323) living in Denmark (latitude: 55°N). Bone mineralisation (n = 108) was measured by DXA. Blood samples were analysed for serum 25-hydroxyvitamin D (s-25(OH)D) by LC-MS/MS, triacylglycerol, and total, low- and high density lipoprotein cholesterol. RESULTS: Mean ± SD s-25(OH)D was 69 ± 23 nmol/L, but varied with season. During winter, 38% had inadequate s-25(OH)D (< 50 nmol), whereof 15% had deficiency (< 30 nmol/L); these numbers were only 7 and 1% during summer. In terms of status determinants, supplement use (66% were users) was associated with s-25(OH)D (P < 0.001), whereas dietary vitamin D intake (median [25-75th percentile] of 1.3 [0.9-1.9] µg/d), sex, parental education, BMI, and physical activity were not. There were no associations between s-25(OH)D and blood lipids or bone measurements, using either unadjusted or adjusted regression models. CONCLUSION: More than 1/3 of Danish toddlers had inadequate vitamin D intake during winter, but acceptable mean vitamin D status. In addition to season, supplement use was the main determinant of vitamin D status, which was, however, not associated with bone mineralisation or lipid profile. The results support recommendations of vitamin D supplements during winter at northern latitudes, but potential health effects need further investigation.

Plasma vitamin B12 concentration is positively associated with cognitive development in healthy Danish 3-year-old children: the SKOT cohort studies.

Adequate vitamin B12 (B12) and folate concentrations are essential for neural development in early childhood, but studies in well-nourished children are lacking. We investigated the relation between plasma B12 and folate at 9 and 36 months and psychomotor development at 36 months in well-nourished Danish children. Subjects from the SKOT cohorts with B12 measurement and completed Ages and Stages Questionnaire, 3rd edition (ASQ-3) at 36 months were included (n 280). Dietary intake, B12 and folate concentrations were collected at 9 and 36 months, and ASQ-3 was assessed at 36 months. Associations between B12 and folate at 9 and 36 months and ASQ-3 were analysed using regression models. Associations between diet and B12 were also investigated. No children had insufficient B12 (<148 pmol/l) at 36 months. B12 at 36 month was positively associated with total ASQ-3 corresponding to an increase of 100 pmol/l B12 per 1·5 increase in total ASQ-3 score (P = 0·019) which remained significant after adjustment for potential confounders including 9 months values. B12 at 9 months or folate at any time point was not associated with total ASQ-3. Intake of milk products was associated with B12 at 36 months (P = 0·003) and showed a trend at 9 months (P = 0·069). Intake of meat products was not associated with B12. In conclusion, B12 was positively related to psychomotor development at 3 years in well-nourished children, indicating that the impact of having marginally low B12 status on psychomotor development in well-nourished children should be examined further.

Vitamin D supplementation and increased dairy protein intake do not affect muscle strength or physical function in healthy 6-8-year-old children: the D-pro randomized trial.

PURPOSE: To investigate separate and combined effects of vitamin D supplementation during the extended winter and increased dairy protein intake on muscle strength and physical function in children, and furthermore to explore potential sex differences. METHODS: In a 2 × 2-factorial, randomized winter trial, 183 healthy, 6-8-year-old children received blinded tablets with 20 µg/day vitamin D3 or placebo, and substituted 260 g/day dairy with yogurts with high (HP, 10 g protein/100 g) or normal protein content (NP, 3.5 g protein/100 g) for 24 weeks during winter at 55° N. We measured maximal isometric handgrip and leg press strength, and physical function by jump tests and a 30 s sit-to-stand test. Physical activity was measured by 7-day accelerometry. RESULTS: Baseline (mean ± SD) serum 25-hydroxyvitamin D was 80.8 ± 17.2 nmol/L, which increased to 88.7 ± 17.6 nmol/L with vitamin D supplementation and decreased to 48.4 ± 19.2 nmol/L with placebo. Baseline protein intake was 15.5 ± 2.4 E%, which increased to 18.4 ± 3.4 E% with HP and was unchanged with NP. We found no separate or combined effects of vitamin D supplementation and/or increased dairy protein intake on muscle strength or physical function (all P > 0.20). There was an interaction on the sit-to-stand test (Pvitamin×yogurt = 0.02), which however disappeared after adjusting for physical activity (P = 0.16). Further, vitamin D supplementation increased leg press strength relatively more in girls compared to boys (mean [95% CI] 158 [17, 299] N; Pvitamin×sex = 0.047). CONCLUSION: Overall, vitamin D and dairy protein supplementation during the extended winter did not affect muscle strength or physical function in healthy children. Potential sex differences of vitamin D supplementation should be investigated further. REGISTERED AT CLINICALTRIALS.GOV: NCT0395673.

Reference serum percentile values of adiponectin, leptin, and adiponectin/leptin ratio in healthy Danish children and adolescents.

The adipokines adiponectin and leptin play key roles in human metabolic regulation and have gained great attention as biomarkers for various metabolic pathologies. Though, pediatric reference values are few and needed. This study aims to establish age- and sex-specific adipokine reference percentiles based on healthy Danish school children. Further, it elucidates sex-specific differences in associations between z-scores of examined adipokines and metabolic variables. Serum adiponectin and serum leptin from 853 observations of healthy Danish schoolchildren aged 8-17 years (median 10.0) were quantified by immunoassays. Age- and sex-specific adipokine reference percentiles were calculated cross-sectionally using the LMS method, and adipokine z-scores were calculated from the fitted model. Multiple linear regression models were used to examine sex-specific differences in associations between adipokine z-scores and various metabolic variables. Girls had a higher median value of adiponectin (11.31 vs. 10.65 µg/mL, p < .001) and leptin (2.30 vs. 1.00 ng/mL, p < .001) and a lower median value of adiponectin/leptin ratio (4.64 vs. 10.76, p < .001) compared to boys. Sex-specific differences were found in associations between adiponectin z-score and HDL (p = .010), between leptin z-score and waist circumference z-score (p = .027) and LDL (p = .048), and between adiponectin/leptin ratio z-scores and waist circumference z-score (p = .044) and LDL (p = .040). Reference percentiles of adiponectin, leptin, and adiponectin/leptin ratio are presented in this paper. To our knowledge, this study is the first to demonstrate sex-specific differences in associations between adipokine z-scores and waist circumference z-score and lipids, respectively in healthy children and adolescents.

Similar effects of milk protein and blends of milk and plant-based protein on appetite-related hormones in 7- to 8-year-old healthy Danish children: secondary analyses from the PROGRO randomised trial.

AIM: The effect of different protein sources on the appetite-related hormones in children is largely unknown. We investigated the effect of milk protein versus blends of milk and rapeseed protein on plasma leptin and adiponectin in children. METHODS: We included 88 Danish 7- to 8-year-old children randomised to receive 35 g protein/day for 4 weeks in 2018 as either milk protein or blends of milk and rapeseed protein (ratio 54:46 or 30:70). Outcomes included absolute and fat mass-adjusted adiponectin and leptin measured at baseline, Weeks 1 and 4. RESULTS: There was no difference in changes in absolute and fat mass-adjusted adiponectin and leptin after 1 or 4 weeks between the three groups (p ≥ 0.100). Leptin increased within all groups (p ≤ 0.046). Combining the three groups, leptin and fat mass-adjusted leptin increased by 23% (95% CI 11;35) and 17% (6.4;29) during the intervention respectively (both p ≤ 0.001). Adiponectin variables did not change during the intervention period. CONCLUSION: There were no differences between milk protein and blends of milk and rapeseed protein on absolute and fat mass-adjusted leptin and adiponectin in healthy children with a habitual intake of milk. However, leptin increased within all three groups. Future studies should further investigate effect on appetite-related hormones of rapeseed protein alone.

Birthweight z-score and fat-free mass at birth predict body composition at 3 years in Danish children born from obese mothers.

AIM: We investigated associations between newborn body composition and anthropometry and body composition at 3 years in Danish children born from obese mothers. METHODS: Analyses are based on data from the observational cohort study SKOT II (SKOT; small children's diet and well-being (Danish)). Body composition at birth and at 3 years was assessed by dual-energy X-ray absorptiometry (DXA) scans and bioelectrical impedance analysis (BIA), respectively. Multiple linear regression models were applied to determine associations between newborn body composition and anthropometry and body composition at 3 years. RESULTS: Birthweight z-score (BWZ) was positively associated with fat-free mass (FFM), height, fat-free mass index (FFMI), fat mass (FM) and fat mass index (FMI) at 3 years. Newborn FFM was positively associated with FFM, height, FFMI and FM at 3 years, and positive trends were seen between newborn FM and FM and FMI at 3 years. CONCLUSION: We showed that infants born with a higher BWZ go on to be taller at 3 years. They also grow to be heavier, to which FM and FFM both contribute, independently of linear growth. Additionally, it seems that FFM tracks into early childhood, thus supporting intrauterine programming of later health.

Impact of timing of PERT on gastrointestinal symptoms in Danish children and adolescents with CF.

AIM: Gastrointestinal (GI) symptoms are often reported by CF patients. Despite a proven relation to exocrine pancreatic insufficiency (PI), it remains unclear whether GI symptoms are related to the timing of pancreatic enzyme replacement therapy (PERT). Whereas most international recommendations suggest administration of PERT at the beginning of meals, it has not been studied whether such a proceeding is associated with lower burden of symptoms. METHODS: Thirty CF patients aged 0-17 years of age with PI were randomised to four weeks of PERT prior to meals followed by four weeks of PERT after meals or vice versa. Using the CF-specific validated CFAbd-Score, abdominal pain, dysfunctional bowel habits and Quality of Life (QoL) related to GI symptoms were assessed in relation to the timing of PERT. Data were analysed using a linear mixed model. RESULTS: There was no significant difference regarding abdominal pain, bowel habits or QoL related to GI symptoms when timing of PERT was changed from prior to after meals. CONCLUSION: No significant difference was found when administration mode of PERT changed from prior to after meals or vice versa. However, after an individual assessment, some patients may profit from changing administration mode of PERT from prior to after meals.

Effect of Fish Oil Supplementation on Hyperlipidemia during Childhood Acute Lymphoblastic Leukemia Treatment - A Pilot Study.

Hyperlipidemia is common during contemporary treatment of childhood acute lymphoblastic leukemia and may increase risk of osteonecrosis, thrombosis, and possibly acute pancreatitis. Marine fatty acids found in fish oil decrease levels of triglycerides and possibly total cholesterol in hyperlipidemic patients. This prospective pilot study provided fish oil for 83 days to seven children undergoing acute lymphoblastic leukemia treatment. On average fish oil was consumed 74% of the intervention period. Further, we found significant lower levels of triglycerides (P = 0.016) and total cholesterol (P = 0.027) compared to 22 historical controls, although correction for one extra PEG-asparaginase dose reduced the level of significance. However, the findings indicate that fish oil may alleviate development of hyperlipidemia during acute lymphoblastic leukemia treatment. Randomized controlled trials are warranted to confirm these findings and to investigate the potential effect of fish oil supplements on development of severe adverse events, including osteonecrosis, thrombosis, and acute pancreatitis.

Effect of probiotics on thymus size and markers of infection in late infancy: a randomized controlled trial.

BACKGROUND: Probiotics are known to stimulate the immune system but the effect on thymus size in late infancy is unknown. We examined the effect of probiotics on thymus size and C-reactive protein (CRP) in healthy Danish infants starting daycare. We further examined associations between thymus size, CRP and recent infections. METHODS: The study included 186 children randomized to a combination of Lactobacillus rhamnosus, LGG® and Bifidobacterium animalis spp. lactis, BB-12® or placebo for 6 months. Thymus size, assessed as thymus index (TI) and thymus weight index (TWI), was measured by ultrasound at baseline and at endpoint. Blood samples were drawn to measure CRP. Infections were parent-reported. RESULTS: There was no significant difference in thymus size between the probiotic group and placebo (p ≥ 0.248) but TWI tended to be higher in the probiotic group corresponding to 5% higher than placebo (p = 0.068) in an adjusted model. There was no effect of probiotics on CRP (p = 0.331). At the endpoint, thymus size was inversely associated with CRP (p ≤ 0.040), diarrhea (p ≤ 0.050), and TI was also associated with the absence from daycare due to respiratory or gastrointestinal infections (p = 0.010). CONCLUSION: The probiotic intervention had no effect on thymus size or CRP in Danish children at the age of starting daycare. IMPACT: Overall there was no effect on thymus size of a combination of Lactobacillus rhamnosus, LGG® and Bifidobacterium animalis spp. lactis, BB-12® administered to Danish children starting daycare. This study examines the effect of probiotics on thymus size in healthy children when they start daycare thus exposed for infections while their immune system is still developing. This has to our knowledge not been described before. We found no significant difference in thymus size between the probiotic and placebo groups, but for thymus weight index, there was a trend. This should be investigated further in studies designed for this as primary outcome.

Sleep and physical activity in healthy 8-9-year-old children are affected by oily fish consumption in the FiSK Junior randomized trial.

PURPOSE: Studies indicate that long-chain n-3 PUFA (n-3LCPUFA) affect sleep and physical activity (PA) in childhood. However, few studies used objective tools and none studies examined the effect of fish per se. We aimed to explore if fish consumption affected sleep and PA assessed by accelerometry in children, and if effects were modified by sex. METHODS: In a randomized 12-week trial, 199 healthy 8-9-year-old children received ~ 300 g/week of oily fish or poultry. Sleep and PA were pre-specified explorative outcomes examined by accelerometers that the children wore on their hip for 7 days at baseline and endpoint, while parents registered sleep. Compliance was verified by erythrocyte n-3LCPUFA. RESULTS: The children slept 9.4 ± 0.5 h/night but the sleep duration variability across the week was 6.0 (95%CI: 0.8, 11.1) min lower in the fish vs poultry group. Furthermore, children in the fish group exhibited increased spare time sedentary activity [9.4 (95%CI: 1.8, 16.9) min/day] at the expense of light PA [- 8.2 (95%CI: - 14.4, - 2.0) min/day]. These effects were supported by dose-dependency with n-3LCPUFA. Additionally, latency to sleep onset was reduced by 3.6 (95%CI: 1.0, 6.3) min on weekends and moderate-vigorous PA during school hours was 3.5 (95%CI: 0.1, 6.8) min longer in fish vs poultry. P values for sex interactions were all > 0.05 but the effects tended to be most pronounced on sleep in girls and PA in boys. CONCLUSION: Oily fish intake altered sleep and PA patterns among healthy schoolchildren, with some slight indications of sex differences. These findings warrant further investigation. CLINICAL TRIAL REGISTRY: At clinicaltrials.gov (NCT02809508) and a published protocol in Trials [Damsgaard et al. in Trials, 2016].

Nutritional screening of children and adolescents with cerebral palsy: a scoping review.

AIM: To examine nutritional screening methods for children and adolescents with cerebral palsy. METHOD: A scoping review was performed using established methodologies. In June 2020 we searched PubMed, Embase, CINAHL Complete, and the Cochrane Central Register of Controlled Trials to identify articles on tools/methods for nutritional screening of our target groups. RESULTS: Thirty studies were included, containing various tools/methods used to identify under- and/or overnutrition by weight/height, circumferences, skinfolds, questionnaires, and/or technically advanced or invasive methods. Questionnaires, weight/height, circumferences, and skinfolds were considered feasible based on clinical utility, whereas bioelectrical impedance analysis and blood samples were not. INTERPRETATION: We identified two screening tools for undernutrition that include no physical measurements, but did not find any screening tools for overweight and obesity. Most of the studies recommended one or more methods, indicating that determining nutritional status most likely includes a combination of methods, not all of which may be feasible in clinical practice. What this paper adds No nutritional screening tool using anthropometry or body composition was discovered. Heterogenous methods to identify under- and/or overnutrition are recommended. Preferable methods for nutritional screening include assessment of body composition. A validated nutritional screening tool for identification of overweight is warranted.

Thymus size and its correlates among children admitted with severe acute malnutrition: a cross-sectional study in Uganda.

BACKGROUND: Malnutrition continues to be a major cause of mortality and morbidity among children in resource limited settings. Children with severe acute malnutrition (SAM) experience severe thymus atrophy, possibly reflecting poor immune function. This immune dysfunction is responsible for the severe infections they experience which lead to mortality. Since their immune dysfunction is not fully understood and there has been a lapse in research in this field, more research is needed. Knowing the correlates of thymus size may help clinicians identify those with more severe atrophy who might have more severe immune impairment. We aimed to describe thymus size and its correlates at admission among children hospitalized with SAM. METHODS: This cross-sectional study involved children 6-59 months admitted with complicated SAM in Mulago National Referral Hospital. Well-nourished children from same communities were used as a community reference group for thymus size. At admission, thymus size was measured by ultrasound scan. Demographic, clinical and laboratory variables were identified at admission. A linear regression model was used to determine correlates of thymus size among children with SAM. RESULTS: Among 388 children with SAM, the mean age was 17±8.5 months and 58% were boys. The mean thymus size was 3.14 (95% CI 2.9; 3.4) cm2 lower than that of the 27 healthy community reference children (1.06 vs 4.2 cm2, p<0.001) when controlled for age. Thymus size positively correlated with current breastfeeding (0.14, 95% CI 0.01, 0.26), anthropometric measurements at admission (weight, length, mid-upper-arm circumference, weight-for-height Z scores and length-for-age Z scores) and suspected tuberculosis (0.12, 95% CI 0.01; 0.22). Thymus size negatively correlated with > 2 weeks duration of sickness (-0.10; 95% CI -0.19; -0.01). CONCLUSION: The thymus is indeed a barometer for nutrition since all anthropometric measurements and breastfeeding were associated with bigger thymus. The immune benefits of breastfeeding among children with SAM is underscored. Children with longer duration of illness had a smaller thymus gland indicating that infections have a role in the cause or consequence of thymus atrophy.

Circulating Insulin-Like Growth Factor-1 Is Positively Associated with Growth and Cognition in 6- to 9-Year-Old Schoolchildren from Ghana.

BACKGROUND: Milk intake stimulates linear growth and improves cognition in children from low-income countries. These effects may be mediated through insulin-like growth factor-1 (IGF-1). OBJECTIVE: The objective was to assess the effect of milk supplement on circulating IGF-1 and to assess IGF-1 as a correlate of growth and cognition in children. METHODS: Secondary data on blood spot IGF-1 from a randomized, double-blind, controlled trial in 6-9-y-old children from rural Ghana were analyzed. Intervention groups received porridge with non-energy-balanced supplements: 8.8 g milk protein/d, 100 kcal/d (Milk8); 4.4 g milk and 4.4 g rice protein/d, 100 kcal/d (Milk/rice); 4.4 g milk protein/d, 48 kcal/d (Milk4); or a control (no protein, 10 kcal/d). IGF-1, length, body composition, and Cambridge Neuropsychological Test Automated Battery (CANTAB) were measured at 3.5 or 8.5 mo. Linear regressions were used to assess the effect of milk interventions on IGF-1 and IGF-1 as a correlate of growth and cognition. RESULTS: The increase in IGF-1 was 15.3 (95% CI: 3.3, 27.3) ng/mL higher in children receiving Milk8 compared with the control. The IGF-1 increases in the isonitrogenous, isoenergetic Milk/rice or the Milk4 groups were not different from the control (P ≥ 0.49). The increase in IGF-1 was associated with improvements in 4 out of 5 CANTAB domains. The strongest associations included reductions in "mean correct latency" from Pattern Recognition Memory and "pre-extradimensional (pre-ED) shift errors" from Intra/Extradimensional Set Shift (P ≤ 0.005). In addition, change in IGF-1 was positively associated with changes in height, weight, and fat-free mass (P ≤ 0.001). CONCLUSIONS: Intake of skimmed milk powder corresponding to one, but not half a glass of milk on school days stimulates IGF-1 in 6-9-y-old Ghanian children. IGF-1 seems to mediate the effect of milk intake on growth and cognition. The association between IGF-1 and cognition in relation to milk intake is novel and opens possibilities for dietary interventions to improve cognition.

Effects of vitamin D supplementation on cardiometabolic outcomes in children and adolescents: a systematic review and meta-analysis of randomized controlled trials.

PURPOSE: In observational studies, higher S-25-hydroxyvitamin D [S-25(OH)D] has been associated with a more favorable cardiometabolic profile in childhood, but results may be confounded. We examined effects of vitamin D supplementation on cardiometabolic outcomes in children and adolescents. METHODS: We systematically searched relevant databases for randomized controlled trials (RCTs) examining effects of vitamin D supplementation compared to placebo or a lower dose of vitamin D on blood glucose, insulin, homeostatic model assessment of insulin resistance (HOMA-IR), glycated hemoglobin, cholesterol [total, high-density, and low-density lipoprotein (LDL-C)], triglycerides, or blood pressure. We conducted random-effects meta-analyses of weighted mean differences in all participants and in subgroups of overweight/obese versus normal weight participants with or without baseline S-25(OH)D < 50 nmol/L. We also explored associations between responses in S-25(OH)D and outcomes by meta-regression. RESULTS: Fourteen RCTs with a total of 1088 participants aged 4-19 years were included. In the meta-analysis, vitamin D supplementation increased S-25(OH)D by 27 nmol/L [95% CI 16; 37] (P < 0.0001) and increased LDL-C by 0.11 mmol/L [0.02; 0.20] (P = 0.02) without any subgroup differences and a generally low to moderate heterogeneity. Vitamin D supplementation had no other effects. However, in the meta-regression analysis, HOMA-IR decreased by 0.51 points [- 0.97; - 0.04] per 10 nmol/L increase in the endpoint S-25(OH)D among overweight/obese participants (P = 0.04). CONCLUSIONS: These results do not support the use of vitamin D supplementation for improving cardiometabolic health in childhood. Indicated beneficial effects on insulin resistance in those with obesity could be investigated further, while unfavorable effects on LDL-C may be a concern.

Is high oily fish intake achievable and how does it affect nutrient status in 8-9-year-old children?: the FiSK Junior trial.

PURPOSE: Most children do not meet dietary guidelines for fish intake. Fish is the main source of EPA (20:5n-3), DHA (22:6n-3) and vitamin D, but may replace better iron sources such as meat. We investigated if intake of 300 g/week oily fish was achievable in children and how it affected their nutrient status. Additionally, we validated a fish food frequency questionnaire (FFQ) by correlations against EPA + DHA in red blood cells (RBC). METHODS: In a randomised 12-week trial, 199 children (8-9 years) received oily fish or poultry (control) to be eaten five times/week. We measured dietary intake and analysed fasting RBC EPA + DHA, serum 25-hydroxyvitamin D (25(OH)D), blood haemoglobin and plasma ferritin. RESULTS: 197 (99%) children completed the study. The median (25th-75th percentile) intake was 375 (325-426) and 400 (359-452) g/week oily fish and poultry, respectively. The fish group increased their intake of EPA + DHA by 749 (593-891) mg/day and vitamin D by 3.1 (1.6-3.8) µg/day. Endpoint RBC EPA + DHA was 2.3 (95% CI 1.9; 2.6) fatty acid %-point higher than the poultry group (P < 0.001). The fish group avoided the expected 25(OH)D winter decline (P < 0.001) and had 23%-point less vitamin D insufficiency (winter subgroup, n = 82). Haemoglobin and ferritin decreased slightly in both groups (P < 0.05), but the number of children with low values did not change (P > 0.14). FFQ estimates moderately reflected habitual intake (r = 0.28-0.35) and sufficiently captured intervention-introduced changes in intake (r > 0.65). CONCLUSION: Oily fish intake of 300 g/week was achievable and improved children's EPA + DHA and 25(OH)D status, without markedly compromising iron status. These results justify public health initiatives focusing on children's fish intake.

Assessment and Interpretation of Vitamin and Trace Element Status in Sick Children: A Position Paper From the European Society for Paediatric Gastroenterology Hepatology, and Nutrition Committee on Nutrition.

Assessment of vitamin and trace element status (VTE) is important in the clinical management of the sick child. In this position paper, we present the various assessment methods available to the clinical practitioner, and critically discuss pitfalls with interpretation of their results. There are 4 main approaches to assess the VTE body status of an individual patient including clinical examination, dietary assessment, and measurement of direct and indirect biomarkers of VTE in biological samples. Clinical signs of VTE deficiencies usually present only when body stores are substantially depleted and are often difficult to detect or differentiate from other nonnutrient-related causes. In isolation, dietary assessment of micronutrients can be inaccurate and imprecise, in disease and in individual patient assessment but may be useful to complement findings from other VTE assessment methods. Use of biomarkers is the most common approach to assess VTE status in routine practice but in the presence of systemic inflammatory response and in the absence of appropriate paediatric reference intervals, interpretation of biomarker results might be challenging and potentially mislead clinical practice. The use of a multimodal approach, including clinical examination, dietary assessment, and laboratory biomarkers is proposed as the optimal way to ascertain the VTE status of individual patients. In the presence of acute inflammatory conditions, VTE measurements in plasma should be replaced by biomarkers not affected by systemic inflammatory response or delayed until inflammatory state is resolved.