Lipid intake in children under 3 years of age in France. A position paper by the Committee on Nutrition of the French Society of Paediatrics.

Lipids are an important source of energy for young children and play a major role in the development and functioning of nervous tissue. Essential fatty acids and their long-chain derivatives also fulfill multiple metabolic functions and play a role in the regulation of numerous genes. The Food and Agriculture Organization of the United Nations (FAO), the World Health Organization (WHO), and the French Agency for Food, Environmental and Occupational Health & Safety (Agence nationale de sécurité sanitaire de l'alimentation, de l'environnement et du travail [ANSES]) have recently recommended a minimum daily intake in preformed long-chain polyunsaturated fatty acids (LC-PUFAs): arachidonic acid (ARA), eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA). Mother's milk remains the only reference, but the large variability in its DHA content does not guarantee that breastfed children receive an optimal DHA intake if the mother's intake is insufficient. For children fed with infant formulas, ARA and DHA intake is often below the recommended intake because only one-third of infant formulas available on the market in France are enriched in LC-PUFAs. For all children, linoleic acid (LA) intake is on average higher than the minimal recommended values. The consequences of these differences between intake and recommended values are uncertain. A cautious attitude is to come close to the current recommendations and to advise sufficient consumption of DHA in breastfeeding women. For bottle-fed children, infant formulas enriched in LC-PUFAs and with moderate levels of LA should be preferred. LC-PUFA-rich fish should be consumed during breastfeeding, and adapted vegetable oils when complementary foods are introduced.

[Breastfeeding: health benefits for child and mother]. / Allaitement maternel: les bénéfices pour la santé de l'enfant et de sa mère.

The prevalence of breastfeeding in France is one of the lowest in Europe: 65% of infants born in France in 2010 were breastfed when leaving the maternity ward. Exclusive breastfeeding allows normal growth until at least 6 months of age, and can be prolonged until the age of 2 years or more, provided that complementary feeding is started after 6 months. Breast milk contains hormones, growth factors, cytokines, immunocompetent cells, etc., and has many biological properties. The composition of breast milk is influenced by gestational and postnatal age, as well as by the moment of the feed. Breastfeeding is associated with slightly enhanced performance on tests of cognitive development. Exclusive breastfeeding for at least 3 months is associated with a lower incidence and severity of diarrhoea, otitis media and respiratory infection. Exclusive breastfeeding for at least 4 months is associated with a lower incidence of allergic disease (asthma, atopic dermatitis) during the first 2 to 3 years of life in at-risk infants (infants with at least one first-degree relative presenting with allergy). Breastfeeding is also associated with a lower incidence of obesity during childhood and adolescence, as well as with a lower blood pressure and cholesterolemia in adulthood. However, no beneficial effect of breastfeeding on cardiovascular morbidity and mortality has been shown. Maternal infection with hepatitis B and C virus is not a contraindication to breastfeeding, as opposed to HIV infection and galactosemia. A supplementation with vitamin D and K is necessary in the breastfed infant. Very few medications contraindicate breastfeeding. Premature babies can be breastfed and/or receive mother's milk and/or bank milk, provided they receive energy, protein and mineral supplements. Return to prepregnancy weight is earlier in breastfeeding mothers during the 6 months following delivery. Breastfeeding is also associated with a decreased risk of breast and ovarian cancer in the premenopausal period, and of osteoporosis in the postmenopausal period.

[Diagnosis of hypochromic microcytic anemia in children]. / Exploration d'une anémie microcytaire chez l'enfant.

Iron deficiency is the most frequent cause of hypochromic microcytic anemia in children, but other causes, some of them requiring specific management, may be involved. Checking the iron-status is absolutely mandatory. When iron-status parameters are low, inadequate intake, malabsorption, blood loss, and abnormal iron utilization must be tested. In absence of iron deficiency, α- and ß-globin and heme biosynthetic gene status must be checked. Assessing the iron stock level is difficult, because there is an overlap between the values observed in iron-replete and iron-deprived patients, so that at least 2 iron-status parameters must be below normal for diagnosing iron deficiency. Furthermore, inflammation may also mimic some characteristics of iron deficiency. Diagnosing iron deficiency leads to prescribing iron supplementation with follow-up at the end and 3 months after cessation of treatment. When iron stores are not replete at the end of treatment, compliance and dosage must be reevaluated and occult bleeding sought. The latter is also required when the iron store decreases 3 months after cessation of iron replacement.

Vitamin D: still a topical matter in children and adolescents. A position paper by the Committee on Nutrition of the French Society of Paediatrics.

The aims of the present position paper by the Committee on Nutrition of the French Society of Paediatrics were to summarize the recently published data on vitamin D in infants, children and adolescents, i.e., on metabolism, physiological effects, and requirements and to make recommendations on supplementation after careful review of the evidence. Scientific evidence indicates that calcium and vitamin D play key roles in bone health. The current evidence, limited to observational studies, however, does not support other benefits for vitamin D. More targeted research should continue, especially interventional studies. In the absence of any underlying risk of vitamin D deficiency, the recommendations are as follows: pregnant women: a single dose of 80,000 to 100,000 IU at the beginning of the 7th month of pregnancy; breastfed infants: 1000 to 1200 IU/day; children less than 18 months of age, receiving milk supplemented with vitamin D: an additional daily dose of 600 to 800 IU; children less than 18 months of age receiving milk not supplemented with vitamin D: daily dose of 1000 to 1200 IU; children from 18 months to 5 years of age: 2 doses of 80,000 to 100,000 IU every winter (November and February). In the presence of an underlying risk of vitamin D deficiency (dark skin; lack of exposure of the skin to ultraviolet B [UVB] radiation from sunshine in summer; skin disease responsible for decreased exposure of the skin to UVB radiation from sunshine in summer; wearing skin-covering clothes in summer; intestinal malabsorption or maldigestion; cholestasis; renal insufficiency; nephrotic syndrome; drugs [rifampicin; antiepileptic treatment: phenobarbital, phenytoin]; obesity; vegan diet), it may be justified to start vitamin D supplementation in winter in children 5 to 10 years of age as well as to maintain supplementation of vitamin D every 3 months all year long in children 1 to 10 years of age and in adolescents. In some pathological conditions, doses of vitamin D can be increased. If necessary, the determination of 25(OH) vitamin D serum concentration will help determine the level of vitamin D supplementation.

Dietary treatment of cows' milk protein allergy in childhood: a commentary by the Committee on Nutrition of the French Society of Paediatrics.

The diagnosis of cows' milk protein allergy (CMPA) requires first the suspicion of diagnosis based on symptoms described in the medical history, and, second, the elimination of cows' milk proteins (CMP) from the infant's diet. Without such rigorous analysis, the elimination of CMP is unjustified, and sometimes harmful. The elimination diet should be strictly followed, at least until 9-12 months of age. If the child is not breast fed or the mother cannot or no longer wishes to breast feed, the first choice is an extensively hydrolysed formula (eHF) of CMP, the efficacy of which has been demonstrated by scientifically sound studies. If it is not tolerated, an amino acid-based formula is warranted. A rice protein-based eHF can be an alternative to a CMP-based eHF. Soya protein-based infant formulae are also a suitable alternative for infants >6 months, after establishing tolerance to soya protein by clinical challenge. CMPA usually resolves during the first 2-3 years. However, the age of recovery varies depending on the child and the type of CMPA, especially whether it is IgE-mediated or not, with the former being more persistent. Once the child reaches the age of 9-12 months, an oral food challenge is carried out in the hospital ward to assess the development of tolerance and, if possible, to allow for the continued reintroduction of CMP at home. Some children with CMPA will tolerate only a limited daily amount of CMP. The current therapeutic options are designed to accelerate the acquisition of tolerance thereof, which seems to be facilitated by repeated exposure to CMP.

[Folic acid and prevention of neural tube closure defects: the question is not solved yet]. / Prévention par l'acide folique des défauts de fermeture du tube neural: la question n'est toujours pas réglée.

Between 1981 and 1996, several interventional studies proved the efficacy of periconceptional folic acid supplementation in the prevention of neural tube closure defects (NTCD), first in women at risk (with a previous case of NTCD) and also in women of the general population in age to become pregnant. The poor observance of this supplementation led several countries (USA, Canada, Chile...) to decide mandatory folic acid fortification of cereals, which permitted a 30% (USA) to 46% (Canada) reduction in the incidence of NTCD. Moreover, this benefit was accompanied by a diminished incidence of several other malformations and of stroke and coronary accidents in elderly people. However, several papers drew attention to an increased risk of colorectal and breast cancer in relation with high blood folate levels and the use of folic acid supplements. A controlled interventional study showed a higher rate of recurrence of colic adenomas and a higher percentage of advanced adenomas in subjects receiving 1mg/day of folic acid. A recent study demonstrated an abrupt reversal of the downward trend in colorectal cancer 1 year after the beginning of cereal folic acid fortification in the USA and Canada. Two studies also reported impaired cognitive functions in elder persons with defective vitamin B(12) status. Taken in aggregate, these studies question the wisdom of a nationwide, mandatory, folic acid fortification of cereals. As of today, despite their limited preventive efficacy, a safe approach is to keep our current French recommendations and to increase the awareness of all caregivers, so as to improve the observance of these recommendations.

[Inversion of the circadian melatonin rhythm in Smith-Magenis syndrome]. / Inversion du rythme circadien de la mélatonine dans le syndrome de Smith-Magenis.

Smith-Magenis syndrome (SMS) is a genetic disease ascribed to an interstitial deletion on chromosome 17 (del 17p11); the prevalence is 1/25,000 births. The diagnosis is made on high-resolution karyotype confirmed by FISH. Clinical features include mild dysmorphism, short stature, other malformations (heart, renal, neurologic diseases). Mental retardation is constant; there are major behavioral disturbances and severe sleep disorders. We studied sleep disorders and melatonin secretion in SMS children and we have shown inversion of the circadian rhythm of melatonin, abnormally secreted during the day. This is the first biological model of behavioral and sleep disorder in a genetic disease. Therapeutic approach using beta-blockers in the morning and melatonin in the evening, reset circadian rhythm of melatonin, improve behavior and restore sleep.

[Feeding of infants based on age. Practice guidelines]. / Alimentation du nourrisson et de l'enfant en bas âge. Réalisation pratique.

This paper presents practical guidelines for nutrition and feeding of infants and toddlers including vitamin D, vitamin K and fluoride supplementations and preventive measures at risk for food allergy based on family history.

[Nutritional treatment of acute diarrhea in an infant and young child]. / Traitement nutritionnel des diarrhées aiguës du nourrisson et du jeune enfant.

This paper written by the Comité de nutrition de la Société française de pédiatrie is specially devoted to the nutritional treatment of infant and child acute diarrhea, i.e. oral rehydration with salts solution and feeding. It complements an article on drug therapy of child acute diarrhea written by the Groupe francophone d'hépatologie, gastroentérologie et nutrition pédiatriques, and published in this same issue of the Archives de pédiatrie.

[Infant formulas and soy protein-based formulas: current data]. / Préparations pour nourrissons et préparations de suite à base de protéines de soja: données actuelles.

For many years soy bean-based formulas (SBBF) were the only dietary product used for infants with cow's milk intolerance. At the present time, their place in infant nutrition is reduced as a result of the availability of new dietary products without lactose and/or cow's milk proteins and the recognition of soy bean protein allergy. There is no evidence that SBBF have any efficiency in infant colic. SBBF have no indication in the prevention of allergy, nor in premature infants' nutrition. Their main indication is the feeding of infants of vegetarian parents who do not want to use cow's milk products. Studies have shown that SBBF contain large quantities of phytoestrogens, particularly isoflavone. Because of experimental data suggesting a possible deleterious effect of phytoestrogens on the neuroendocrine maturation, the reduction of their content in SBBF must be considered.

[Iron and pregnancy]. / Fer et grossesse.

Infants, young children, and childbearing aged women are particularly exposed to iron deficiency. Pregnancy further increases iron requirements. Nevertheless the consequences of anemia and/or iron deficiency on pregnancy outcome, development of the foetus and postnatal iron status of the infant, remain to be determined. There is a 3-fold increase of premature deliveries in iron deficient anemic pregnant women whose anemia is discovered in early pregnancy: however this increased risk of premature delivery is not observed when iron deficiency anemia is discovered in late pregnancy. Iron supplementation during pregnancy improves the maternal hematological parameters but it is still unclear whether it also improves the maternal health and the pre and postnatal development of the child. Based on our actual knowledge, iron supplementation during pregnancy is to be recommended in risk groups only (ie mainly adolescents, low income women, women with multiple pregnancies), using ferrous iron at a dosage of 30 mg per day.

Cloning of cDNAs encoding a rat neuropeptide immunologically related to salmon melanin-concentrating hormone.

In order to identify the neuropeptide related to melanin-concentrating hormone (MCH) synthetized by neurons of the posterior hypothalamus in the mammals, we have screened rat hypothalamus and rat brain cDNA expression libraries using MCH antiserum. We isolated 5 distinct immunopositive recombinants with cross-hybridizing cDNA inserts. One of them hybridized to RNAs exclusively located in neurons stained by the same antiserum, as seen by successively performing in situ hybridization and then an immunocytochemical technique on the same section. Sequencing of this MCH-like cDNA is in progress.

[Cloning of the cDNA, while encoding a hypothalamic neuropeptide in the rat, related to the melanin-concentrating hormone in the salmon]. / Clonage d'un ADNc codant un neuropeptide hypothalamique de rat apparenté à l'hormone de mélano-concentration du Saumon.

In order to identify the neuropeptide related to salmon melanin-concentrating hormone (MCH) synthetized by neurons of the posterior hypothalamus in the mammals, we have screened rat hypothalamus and rat brain cDNA expression libraries using MCH antiserum. Five recombinants were isolated, which cDNAs were amplified using the polymerase chain reaction. One of them hybridized to RNAs exclusively located in hypothalamic neurons stained by the same antiserum, as seen by performing in situ hybridization and immunocytochemical techniques on the same section. The sequence analysis showed that this cDNA corresponds to the end of the open reading frame encoding a MCH-like peptide and to the 3' untranslated region. The rat MCH is very similar to salmon MCH (greater than 85% homologies in the 14C-terminal residues).

Human corticoliberin hypothalamic neuroglandular system: comparative immunocytochemical study with anti-rat and anti-ovine corticotropin-releasing factor sera in the early stages of development.

Development of the paraventriculo-infundibular corticoliberin system was studied by immunocytochemical analysis of human hypothalamic sections using antisera raised against rat or ovine corticotropin-releasing factor (CRF). This comparative study confirms the presence of a significant number of CRF-immunoreactive fibers in the median eminence during the 16th week of fetal development and suggests they may appear as early as the 14th week. Some hypothalamic peri- and paraventricular neurons, observed from the 12th week, are rat-CRF-immunoreactive but not ovine CRF-immunoreactive. There appears to be chronological differences concerning the ability of the two antisera to recognize hypothalamic structures during the early stage of development.

[Ontogenetic data on the peptidergic interneuronal population in immunoreactivity of the GRF 37 type serum of the human posterolateral hypothalamus. Immunocytochemical studies using anti-GRF 37 and anti-MCH (melanin-concentrating hormone) immune sera]. / Données ontogénétiques sur la population d'interneurones peptidergiques à immunoréactivité de type GRF 37 de l'hypothalamus postéro-latéral humain. Etudes immunocytochimiques à l'aide d'un IS anti-GRF 37 et d'un IS anti-MCH (melanin-concentrating hormone).

Human posterolateral hypothalamic neurons are revealed with an anti GRF 37 serum as soon as the 7th week of fetal life. The same neuronal population can be observed in the adult brain even in hypothalami from old subjects, with the same distribution, and similar immunoreactivity than in fetal stages. These neurons are revealed using a melanin concentrating hormone (MCH) antiserum; the MCH immunoreactivity appears at the same stage of fetal development than GRF 37 immunoreactivity. The two antisera recognize two epitopes on one or two molecules. Those new facts agree with an hypothesis about the very important and permanent functional role of that new human hypothalamic interneuronal system.

[Contribution of immunocytochemistry to the study of the development of neuroglandular peptidergic systems in the human fetal hypothalamus]. / Apport de l'immunocytochimie à l'étude du développement de systèmes neuroglandulaires peptidergiques dans l'hypothalamus foetal humain.

Immunohistochemistry makes possible the in situ detection of neuropeptides in the cell bodies were they are synthesized, in the fibers that carry them, and in endings. Immunohistochemistry appears necessary to identify and map peptidergic neurons and to study their ontogeny. From 1975, we have carried the immunohistochemical study of several hypothalamic neuronal populations in the human fetus: LH-RH (1976), somatostatin (1977), pro-opiocortin (1978), vasopressin and oxytocin (1979), corticoliberin (1982), somatocrinin (1983), and hypothalamic neurons containing an unidentified peptide (1984). Comparative ontogenetical studies have also been performed in rats.

[Ontogenesis in man, of a population of neurons in the dorsal and lateral hypothalamus, secretors of a peptide that has not yet been characterized]. / Ontogenèse chez l'homme, d'une population de neurones de l'hypothalamus dorsal et latéral, sécréteurs d'un peptide non encore caractérisé.

A human GRF 1-37 antiserum demonstrates a new neuronal system in lateral perifornical areas of the human hypothalamus. The molecule that is revealed in those neurons cannot be somatocrinin. Perikarya are abundant. They are observed beginning with the 9th week of development. alpha-MSH-like immunoreactivity, which is showed in the analogous cells of the rat, is not yet established in human. The early differentiation of those neurons and their abundance during the fetal life attest to the important neurophysiological function of the unidentified peptide they secrete.

Anatomical and ontogenetic studies of the human paraventriculo-infundibular corticoliberin system.

In human fetus, newborn, infant and adult hypothalami, antibodies to ovine corticoliberin-41 stain a paraventriculo-infundibular neuroglandular pathway. The perikarya are located in the paraventricular nucleus, they mainly project to the ventral and lateral areas of the median eminence. Eminential corticoliberin-positive fibres appear during the 16th week of fetal life, and increase in number during the following weeks. Perikarya were first revealed in the 19th week. In some areas of the median eminence, corticoliberin-, vasopressin- or [Met]enkephalin-immunoreactive terminals are similarly distributed. Sequential stainings or staining comparison of contiguous semi-thin sections failed to prove the coexpression of corticoliberin and [Met]enkephalin immunoreactivities in fibres, but indicated that corticoliberin and vasopressin immunoreactivities may be coexpressed in a few fibres. Those methods enabled us to observe, in the paraventricular nucleus, perikarya revealed by corticoliberin and vasopressin antisera. Our results suggest a possible release of corticoliberin in portal vessels of the median eminence beginning in the 16th week of fetal life, i.e. 8 weeks later than appearance of the corticotrophs in the pituitary. Establishment of a corticoliberin hypothalamic control of pituitary corticotrophs at mid gestation agrees with previous physiological and teratological studies. Abundance, as well as immunostaining intensity of the corticoliberin processes, in the infant and adult median eminence attest to the physiological importance of this system. Close vicinity of corticoliberin, vasopressin and [Met]enkephalin fibres, in some eminential areas and coexpression of corticoliberin and vasopressin immunoreactivities in some neurons, are morphological correlates of functional relations which were reported.