Trace Element Provision in Parenteral Nutrition in Children: One Size Does Not Fit All.

Routine administration of trace elements is recognised as a standard of care in children requiring parenteral nutrition. However, there is a lack of global consensus regarding trace elements provision and dosing in pediatric parenteral nutrition. This review provides an overview of available evidence regarding trace elements supply and posology in parenteral nutrition in neonates and children. Trace elements provision in children should be tailored to the weight and clinical condition of the child with emphasis on those at risk of toxicity or deficiency. Based on current evidence, there is a need to review the formulation of commercial solutions that contain multiple-trace elements and to enable individual trace elements additives to be available for specific indications. Literature supports the removal of chromium provision whereas manganese and molybdenum supplementation are debated. Preterm neonates may have higher parenteral requirements in iodine, selenium and copper than previously recommended. There is growing support for the routine provision of iron in long-term parenteral nutrition. Further studies on trace elements contamination of parenteral nutrition solutions are needed for a range of trace elements.

Effects of Excess Dietary Fluoride on Serum Biochemical Indices, Egg Quality, and Concentrations of Fluoride in Soft Organs, Eggs, and Serum of Laying Hens.

This study was conducted to investigate the effects of excess dietary fluoride (F) on serum biochemical indices, egg quality, and concentrations of F in soft tissues, eggs, and serum of laying hens. Commercial laying hens (n = 576, 51 weeks of age) were randomly allotted to 6 treatments with 6 replicates of 16 birds. The basal diets contained fluorine inclusions at a level of 16 mg/kg, and graded sodium fluoride was added to the basal diet to achieve fluorine inclusions, respectively, at a level of 200, 400, 600, 800, and 1000 mg/kg in the experimental diets. Dietary F levels at 600, 800, and 1000 mg/kg decreased (P < 0.05) albumin height and yolk color, while eggshell strength and eggshell thickness significantly decreased at 800 and 1000 mg/kg, respectively, compared with the control group. Fluoride concentrations in eggshell, albumin, yolk, liver, kidney, ovary, and oviduct responded to dietary F levels positively, and F concentrations in eggshell were the highest. Fluorine concentrations in albumin and yolk increased with the feeding time at the same dietary F levels (P < 0.05). Dietary F level at 400 mg/kg increased serum calcium level and activity of glutamic oxalacetic transaminase (P < 0.05). In conclusion, dietary F levels at 600 mg/kg decreased albumin height and yolk color, while eggshell strength and eggshell thickness significantly decreased at 800 and 1000 mg/kg, respectively. F concentrations in soft tissues, albumin, yolk, and eggshell of layers had a positive correlation with dietary F levels. By disturbing Ca and phosphorus metabolism, dietary F levels affected the formation of eggshell, reducing eggshell strength and eggshell thickness.

Skeletal fluorosis from brewed tea.

BACKGROUND: High fluoride ion (F(-)) levels are found in many surface and well waters. Drinking F(-)-contaminated water typically explains endemic skeletal fluorosis (SF). In some regions of Asia, however, poor quality "brick tea" also causes this disorder. The plant source of brick, black, green, orange pekoe, and oolong tea, Camellia sinensis, can contain substantial amounts of F(-). Exposure to 20 mg F(-) per day for 20 yr of adult life is expected to cause symptomatic SF. High F(-) levels stimulate osteoblasts and enhance bone apposition but substitute for OH(-) groups in hydroxyapatite crystals and thereby result in skeletal fragility and perhaps lead to secondary hyperparathyroidism. Beginning in 2005, we showed that daily consumption of 1-2 gallons of instant tea made from this plant can lead to SF. AIM: We describe a 48-yr-old American woman who developed SF from brewed tea. PATIENT AND METHODS: Our patient had elevated bone mineral density revealed by dual-energy x-ray absorptiometry (spine Z-score, +9.9), severe chronic bone and joint pain, and kyphosis after consuming 1-2 gallons of brewed orange pekoe tea daily for more than three decades. F(-) levels were high in her serum, urine, and clippings of fingernails and toenails, as well as in our reproduction of her beverage. Renal function was normal. She had vitamin D deficiency. Elevated serum PTH levels were unresponsive to adequate vitamin D supplementation. Pain resolved over several months when she stopped drinking tea and continued ergocalciferol. CONCLUSION: Our patient shows that SF can result from chronic consumption of large volumes of brewed tea.

Serum fluoride and sialic acid levels in osteosarcoma.

Osteosarcoma is a rare malignant bone tumor most commonly occurring in children and young adults presenting with painful swelling. Various etiological factors for osteosarcoma are ionizing radiation, family history of bone disorders and cancer, chemicals (fluoride, beryllium, and vinyl chloride), and viruses. Status of fluoride levels in serum of osteosarcoma is still not clear. Recent reports have indicated that there is a link between fluoride exposure and osteosarcoma. Glycoproteins and glycosaminoglycans are an integral part of bone and prolonged exposure to fluoride for long duration has been shown to cause degradation of collagen and ground substance in bones. The present study was planned to analyze serum fluoride, sialic acid, calcium, phosphorus, and alkaline phosphatase levels in 25 patients of osteosarcoma and age- and sex-matched subjects with bone-forming tumours other than osteosarcoma and musculo-skeletal pain (controls, 25 each). Fluoride levels were analyzed by ISE and sialic acid was analyzed by Warren's method. Mean serum fluoride concentration was found to be significantly higher in patients with osteosarcoma as compared to the other two groups. The mean value of flouride in patients with other bone-forming tumors was approximately 50% of the group of osteosarcoma; however, it was significantly higher when compared with patients of group I. Serum sialic acid concentration was found to be significantly raised in patients with osteosarcoma as well as in the group with other bone-forming tumors as compared to the group of controls. There was, however, no significant difference in the group of patients of osteosarcoma when compared with group of patients with other bone-forming tumors. These results showing higher level of fluoride with osteosarcoma compared to others suggesting a role of fluoride in the disease.

Comparative study of p38 MAPK signal transduction pathway of peripheral blood mononuclear cells from patients with coal-combustion-type fluorosis with and without high hair selenium levels.

Coal-combustion-type fluorosis has only been reported in China and its pathogenesis has not been fully understood. Fluoride causes chronic toxic effects and selenium modulates cellular activities through signal transduction in human cells. The present study enrolled three groups of subjects with well-defined serum and urine fluoride and hair selenium: high fluoride+high selenium group, high fluoride group and normal control group. The expressions of p38, NF-kB p65, caspase-3 and p53 genes at both protein and mRNA levels in peripheral blood mononuclear cells (PBMCs) were determined by Western blotting and quantitative real-time RT-PCR, respectively. The results showed that the expressions of p38, NF-kB p65, and caspase-3 protein in high fluoride group were higher than those in the other two groups. The mRNA level of NF-kB p65 and caspase-3 was significantly higher in high fluoride+high selenium group than control and lower than high fluoride group. The mRNA and protein level of p53 was significantly higher in high fluoride+high selenium group than that in other two groups. These results suggest that selenium may influence the protein and gene expression associated with p38 signal transduction pathway and up-regulate p53 expression in PBMCs from patients with coal-combustion-type fluorosis.

Evaluation of free radical-scavenging and anti-oxidant properties of black berry against fluoride toxicity in rats.

Oxidative damage to cellular components such as lipids and cell membranes by free radicals and other reactive oxygen species is believed to be associated with the development of degenerative diseases. Fluoride intoxication is associated with oxidative stress and altered anti-oxidant defense mechanism. So the present study was extended to investigate black berry anti-oxidant capacity towards superoxide anion radicals, hydroxyl radicals and nitrite in different organs of fluoride-intoxicated rats. The data indicated that sodium fluoride (10.3mg/kg bw) administration induced oxidative stress as evidenced by elevated levels of lipid peroxidation and nitric oxide in red blood cells, kidney, testis and brain tissues. Moreover, significantly decreased glutathione level, total anti-oxidant capacity and superoxide dismutase activity were observed in the examined tissues. On the other hand, the induced oxidative stress and the alterations in anti-oxidant system were normalized by the oral administration of black berry juice (1.6g/kg bw). Therefore it can be concluded that black berry administration could minimize the toxic effects of fluoride indicating its free radical-scavenging and potent anti-oxidant activities.

Fluoride-related bone disease associated with habitual tea consumption.

Acquired osteosclerosis is a rare disorder of bone formation but an important consideration in adults with sclerotic bones or elevated bone density results. In such patients, malignancy, hepatitis C, and fluorosis should all be considered when making a diagnosis. We describe 4 patients evaluated at our Metabolic Bone Disease Clinic from May 1, 1997, to July 1, 2006, whose bone disorders resulted from chronic fluoride exposure due to excessive tea intake. Three of these patients had toxic serum fluoride levels (> 15 micromol/L). Although the clinical presentation of the patients varied, all 4 had an unexpectedly elevated spine bone mineral density that was proportionately higher than the bone mineral density at the hip. Other clinical features included gastrointestinal symptoms such as nausea, vomiting, and weight loss; lower extremity pain sometimes associated with stress fractures of the lower extremities; renal insufficiency; and elevated alkaline phosphatase levels. Readily available, tea often contains high levels of fluoride. Obsessive-compulsive drinking behaviors and renal insufficiency may predispose to excessive fluoride consumption and accumulation. The current cases show that fluoride-related bone disease is an important clinical consideration in patients with dense bones or gastrointestinal symptoms and a history of excessive tea consumption. Furthermore, fluoride excess should be considered in all patients with a history of excessive tea consumption, especially due to its insidious nature and nonspecific clinical presentation.

Influence of sodium fluoride and caffeine on the concentration of fluoride ions, glucose, and urea in blood serum and activity of protein metabolism enzymes in rat liver.

The aim of the study was examining the effect of fluoride ions and caffeine administration on glucose and urea concentration in blood serum and the activity of protein metabolism enzymes and selected enzymes of the urea cycle in rat liver. The study was carried out using 18 male Sprague-Daowley rats (4.5 mo old). Rats were divided into three groups. Group I received distilled water ad libitum. Group II received 4.9 mg F-/kg body mass/d of sodium fluoride in the water, and group III received sodium fluoride (in the above-mentioned dose) and 3 mg/kg body mass/d of caffeine in the water. After 50 d, the rats were anesthetized with thiopental and fluoride ions, glucose, and urea concentration in blood serum were determined. Also determined were the activities of aspartate aminotransferase, alanine aminotransferase glutamate dehydrogenase, ornithine carbamoylotransferase and arginase in liver homogenates. Liver was taken for pathomorphological examinations. The applied doses of F- (4.9 mg/kg body mass/d) and F- + caffeine (4.9 mg F-/kg body mass/d + 3 mg caffeine/kg body mass/d) resulted in a statistically significant increase of fluoride ion concentration in blood serum, a slight increase of the glucose concentration, and no changes in the concentration of urea in blood serum. This might testify to the absence of kidney lesions for the applied concentrations of F-. No change in the functioning of hepatocytes was observed; however, slight disturbances have been noted in the functioning of the liver, connected with the activation of urea cycle, increase of arginase activity, and accumulation of F- in this organ. There was no observed significant influence of caffeine supplementation on the obtained results.

Reversal of fluoride induced cell injury through elimination of fluoride and consumption of diet rich in essential nutrients and antioxidants.

The objective of the present communication is to address the issues concerning reversal of fluoride induced cell injury and disease (i.e. fluorosis) through the elimination of fluoride and consumption of a diet containing essential nutrients and antioxidants. Humans afflicted with fluorosis, as a result of consuming fluoride contaminated water or food, have been investigated. Hospital based diagnostic procedure for early detection of fluorosis, through retrieval of history, clinical complaints, testing of blood, urine and drinking water for fluoride using ion selective electrode technology, along with X-ray of the forearm have been carried out. Confirmed cases of fluorosis were introduced to an intervention protocol consisting of (1) provision of safe drinking water with fluoride levels less than 1 mg/L and (2) counselling on nutritional supplementation with focus on adequate intake of calcium, vitamins C, E and antioxidants. The patients were monitored at frequent intervals up to one year and the results are reported. With a standardized early diagnosis, elimination of fluoride intake and supplementation of a diet rich in essential nutrients and antioxidants, we have shown that the fluorosis can be reversed.

Effects of caffeine on fluoride, calcium and phosphorus metabolism and calcified tissues in the rat.

This 6-week study was designed to determine the effects of graded doses of caffeine intake (3, 25 or 100 mg/kg per day) on the metabolic balance and tissue concentrations of fluoride, calcium and phosphorus in Sprague-Dawley rats. Caffeine intake did not affect the absorption, urinary excretion or balance of fluoride, the plasma, bone or enamel concentrations of fluoride, nor the occurrence of incisor enamel fluorosis. Neither did it affect the metabolism of calcium or phosphorus except that the urinary excretion of calcium was increased. This effect, however, was not sufficient to influence significantly calcium balance. The ash content of the femur epiphysis and bone mineral content of the tibia were significantly reduced only in the group exposed to the highest dose of caffeine. These effects on bone were not significantly related to the balance of calcium or phosphorus. It was concluded that caffeine, even at an extremely high level of intake, has no detectable effect on the balance or tissue concentrations of fluoride, calcium or phosphorus in the rat.

[Evaluation of the repair process in mechanically injured rat bone stimulated by sodium fluoride with non-toxic doses]. / Ocena przebiegu procesu reparacyjnego mechanicznie uszkodzonej kosci szczura, stymulowanego fluorkiem sodu w dawce nietoksycznej.

The influence of sodium fluoride on the course of repair process in the mechanically injured rat bone was studied. Thirty six male Wistar rats aged 5 months, weighing 460-540 g were investigated. The animals lived under standard conditions and were fed ad libidum with the standard LSM food including 0.7 mg/kg of fluorine on the average. The animals randomly divided into 3 groups that comprised study and control groups, 6 rats each. The rats in the first group were given water with 20 mg (1.05 mmol) of sodium fluoride per kg of body weight for 24 h over a period of 2 weeks--group Ia. In the second group--IIa--animals were given water with sodium fluoride at a dose of 1.5 mmol/kg b.w./24 h for a period of 4 weeks. In the third group--IIIa--the animals were given sodium fluoride in a dose of 1.5 mmol/kg b.w./24 h for a period of 6 weeks. The rats from the control groups I, II and III were given water without sodium fluoride for the period of 2, 4 and 6 weeks, respectively. At the beginning of the experiment a hole was drilled in both femoral bones in rat under barbiturate anaesthesia. According to the protocol the rats underwent ether euthanasia after 2, 4 and 6 weeks after surgery and the following samples were collected: blood from the heart for biochemical studies and both femoral bones for biochemical and histological studies. The following parameters were evaluated in blood serum: fluorine, calcium, magnesium contents, serum concentrations of urea, creatinine, bilirubin and activity levels of enzymes: aspartate aminotransferase, alanine aminotransferase, cholinesterase, base phosphatase. Fluorine, calcium magnesium and zinc contents were estimated in bone samples. The concentration of fluorine ions in animal serum after 2, 4 and 6 weeks of experiment increased significantly as compared with the corresponding controls. The highest fluorine concentrations were observed in serum of rats supplemented with NaF for 6 weeks. The fluorine concentrations in the bone tissue and fresh and dried granulation tissues in all studied groups also revealed statistically significant increase as compared to the controls. The rats fed with sodium fluoride for the period of 6 weeks revealed statistically significant increase of serum magnesium concentration as compared to the remaining study groups. Bone magnesium concentrations in animals fed with NaF for the period of 2 and 6 weeks were higher as compared to the corresponding control groups, with the highest differences observed after 6 weeks of experiment. Animals fed with sodium fluoride for the period of 6 weeks revealed increased serum calcium concentrations as compared to the study groups after 2 and 4 weeks of experiment. Similar results were achieved in bone tissue samples (Fig. 1 and 2, Tab. 1-6). Basing on the achieved results in biochemical studies and histological pictures it should be assumed that laboratory animals fed with sodium fluoride in doses recognised as non-toxic reveal intensified healing process within mechanically injured bones. The use of sodium fluoride led to accelerated chondrogenesis process in the area of insufficiently perfused bone, osteogenesis including temporary callus formation and mineralization of the new bone, as well as remodelling into mature lamellar bone. The greatest differences in the repair dynamics for both groups occurred between the second and fourth week of experiment. These results could be the base of clinical studies on application of the sodium fluoride in the acceleration of fracture healing.

Long-term follow up of ionic plasma fluoride level in patients receiving hemodialysis treatment.

The elimination half-life of fluoride is significantly increased in patients with chronic renal failure. This led us to conduct a study of variations of its plasma levels in 35 patients receiving dialysis treatment. In this population, there is a gaussian distribution of the values before and after the hemodialysis session, with a significant decrease in the averages. Furthermore, there is a highly significant correlation between fluoride levels before and after the dialysis session (P < 0.00001), and also between the amount of time in hemodialysis (in months) and the average fluoride level before dialysis (r = 0.624; P = 0.008). The presence of a group of patients consuming fluoride waters such as Vichy St-Yorre Water was easily identified by their excessive fluoride levels (above 100 micrograms/l), which could have a tendency to increase the risks of this group.

The effect of hemodialysis upon serum levels of fluoride.

Serum and dialysate ionic fluoride (F-) were determined in 29 patients under hemodialysis (HD) treatment. Serum creatinine (Cr), blood urea nitrogen (BUN) and phosphorus (P) were also examined before and after HD in 92 patients including the above 29 patients under the same treatment. Results reveal that serum F- levels of the patients before and after HD were statistically higher than those of the healthy subjects. The dialysis clearance of F- was 55.6 +/- 101.3 ml/min and the value was statistically significantly lower than those of Cr, BUN (95%, p < 0.001) and P (95%, p < 0.01). Based on these results, it is concluded that despite a net clearance of F- during a given HD procedure, serum F- failed to return to normal.

Chemical and X-ray analysis of fluoride, phosphorus, and calcium in human foetal blood and hard tissues.

To evaluate the beneficial effect of prenatal fluoride supplementation, the presence of fluoride in hard tissues in two populations of human foetuses coming from fluoridated (> or = 0.7 parts/10(6) F in drinking water) and non-fluoridated areas (< or = 0.1 parts/10(6) F in drinking water) were compared by chemical analysis and X-ray microanalysis. The fluoride concentrations measured in maternal and venous cord blood confirmed that placental transfer of fluoride was passive when fluoride intake was low. Total fluoride contents of tooth germs and mandibular bone appeared to increase with fluoride level in drinking water. However, these concentrations were too low to be detected by X-ray microanalysis. Phosphorus and calcium total contents were identical in mandibular and femoral bone of both populations. In incisor germs, phosphorus and calcium concentrations in enamel and dentine close to the amelodentinal junction did not differ significantly between the two populations. It is suggested that the low fluoride concentrations in enamel and dentine formed in utero would not have a significant effect on acid solubility.

Effect of disodium monofluorophosphate, calcium and vitamin D supplementation on bone mineral density in patients chronically treated with glucocorticosteroids: a prospective, randomized, double-blind study.

To study the effect of fluoride on bone mineral density (BMD) in patients treated chronically with glucocorticosteroids, 15 subjects (renal grafted, n = 12; skin disease, n = 1; broncho pulmonary disorder, n = 1; Crohn's disease, n = 1) were prospectively studied in a double-blinded manner and randomly allocated either to group 1 (n = 8) receiving 13.2 mg/day fluoride given as disodium monofluorophosphate (MFP) supplemented with calcium (1,000 mg/day) and 25-hydroxyvitamin D (calcifediol) (50 micrograms/day), or to group 2 (n = 7) receiving Cas+ calcifediol alone. An additional group of 14 renal transplant patients treated chronically with glucocorticosteroids but exempt of specific therapeutic intervention for bone disease was set up as historical controls. BMD was measured by dual-energy X-ray absorptiometry (DXA, Hologic QDR 1000) performed at months 0, 6 and 12 for groups 1 and 2 (lumbar spine, total upper femur, diaphysis and epiphysis of distal tibia), or 11-31 months apart with calculation of linear yearly changes for the historical cohort. Lumbar BMD tended to rise in groups 1 and 2, and to fall in group 3, the change reaching statistical significance (p < 0.05) in group 1, thus leading to a significant difference between groups 1 and 3 (p < 0.05). At upper femur, tibial diaphysis and tibial epiphysis, no significant change in BMD occurred in any of the groups. In conclusion, lumbar BMD rises more after a mild dosis of fluoride given as MFP and combined to calcium and calcifediol than on Ca+ calcifediol alone, without changes in BMD at the upper femur or distal tibia.

Safety of ciprofloxacin therapy in children: magnetic resonance images, body fluid levels of fluoride and linear growth.

We evaluated the safety of ciprofloxacin administered in a dose of 15-25 mg/kg for 9-16 days, in a case series of 58 children who were between 8 months and 13 years of age. No arthropathy was observed during therapy and follow-up. Blinded evaluation of 22 pairs of nuclear magnetic resonance scans obtained before and between day 10 and 15 of therapy did not reveal any cartilage damage. After the first dose of ciprofloxacin (10 mg/kg), serum fluoride levels increased at 12 h in 15 of 19 (79%) patients; 24-h urinary fluoride excretion was higher on day 7 compared with basal values in 16 of 18 (88.9%) patients. Height z scores of 53 patients at a mean of 22.5 months of follow-up were not significantly different from basal scores (p = 0.12). In conclusion, ciprofloxacin may be recommended for use in children for short duration when effective alternative antibacterials are unavailable. However, there is a need for further studies to evaluate the tissue accumulation of fluoride and its potential to cause toxic effects.

Toothpaste technique. Studies on fluoride delivery and caries prevention.

The aim of the investigations was to evaluate the cariostatic effects of a modified toothpaste technique using fluoride (F) toothpaste. The modification consisted of an active mouthrinse with the toothpaste slurry and a sip of water for one minute after brushing. Toothpaste technique and salivary F concentration after toothbrushing were recorded in a caries active and a caries inactive group. The level of F in whole saliva, the concentration of F in plasma, the effect on demineralised enamel and dentine samples, and the accumulation of F in interdental plaque when using the modified toothpaste technique were studied. In a 3-year clinical trial, 4-year old children were trained in the toothpaste technique. The results showed that in the caries active group, the water rinsing was more thorough and more water was used compared to a caries inactive group. Rinsing with water and eating immediately after toothbrushing decreased the F level in whole saliva. Mouthrinsing with either a NaF solution or a slurry of toothpaste foam and water increased the F concentration in saliva compared to when a single or double water rinse was performed. The degree of F absorption in plasma, the accumulation of F in approximal plaque and the interdental clearance after toothbrushing were strongly related to the mode of water rinsing. The degree of demineralisation of enamel and dentine at approximal sites was also related to the mode of water rinsing. The clinical study showed that the cariostatic effect of the modified toothpaste technique resulted in 26% less approximal caries in the test group. It is concluded that a toothpaste technique where a slurry rinse was carried out after brushing increased the efficacy of F toothpaste.

The effect of fluoride therapy on blood chemistry parameters in osteoporotic females.

To determine the potential adverse effects, if any, of long-term fluoride ingestion in humans, samples were collected from 25 adult females taking daily doses of fluoride (mean, 23 mg elemental F) for the treatment of osteoporosis and from 38 osteoporotic female controls. Patients in the fluoride group had been receiving therapy for approximately 18 months with a mean duration of 4.2 years and had serum fluoride values of at least 10 mumol/l. Laboratory analyses for fluoride were conducted on plasma, urine and drinking water samples collected from each panelist. Blood was also collected for blood chemistry analyses and plasma lymphocytes were examined for the frequency of sister chromatid exchange (SCE). Plasma and urine fluoride levels were significantly different between the two groups, while water fluoride was not. The SCE frequency, a measurement of potential genotoxicity, did not differ between the two groups. Of the blood chemistry parameters measured, albumin, alkaline phosphatase, sodium, chloride, the albumin/globulin (A/G) ratio, indirect bilirubin, lactate dehydrogenase (LDH), and gamma-glutamyl transferase (GGT) were found to be significantly different between the two groups (P < or = 0.05). However, none of the mean group values were outside stated normal ranges for any of these parameters. We conclude that the risk of developing adverse systemic effects from the ingestion of fluoride, at dosages and for a duration comparable with that of our panel, is minimal.