Breastfeeding duration is associated with higher adiposity at 6-8 months of age.

Breastfeeding (BF) has been identified as a protective factor against childhood obesity. However, evidence of the association between BF duration and adiposity remains inconclusive. Few studies have been conducted among Southeast Asian infants that have measured body composition during infancy using the gold standard stable isotope method. This study aimed to evaluate the association between BF duration and body composition during infancy. Healthy full-term Thai infants aged 6-8 months (n = 60) receiving exclusive or predominant BF for at least 3 months were recruited. Skinfold thickness (SFT) was measured by well-trained investigators. Body composition was assessed by the deuterium dilution technique. Infants with longer BF duration (>6 months; mean 7.5 ± 0.5 months, n = 29) had a higher subscapular SFT z-score than those with shorter BF duration (≤6 months; mean 5.3± 0.9 months, n = 31) by 0.48 (95% confidence interval [CI]: 0.01-0.94). After adjustment for age and sex, BF duration and age at introduction of complementary feeding (CF) were positively associated with fat mass and fat mass index at 6-8 months. One month increase in BF duration and CF age was associated with a 0.37 (95% CI: 0.05, 0.69) kg/m2 and 0.76 (95% CI: 0.18, 1.34) kg/m2 increase in the fat mass index, respectively. After adjusting for infant body mass index (BMI) during the earlier infancy period, the strength of the association was attenuated. This finding may reflect reverse causality where infants with lower BMI received formula or CF earlier. A longitudinal study with follow-up into childhood is warranted to confirm the effects of BF on adiposity in infancy and childhood.

Effects of low-glycemic index diet on plasma adipokines in obese children.

BACKGROUND: A low-glycemic index (GI) diet may modulate adipocyte-produced adipokines linking to insulin resistance. METHODS: The stored plasma samples from the RCT of a low-GI vs. conventional diet in obese children were analyzed for adipokines: leptin, adiponectin, resistin, and visfatin. Their relationships with clinical outcomes were assessed. RESULTS: Fifty-two participants completed the 6-month intervention trial (mean age: 12.0 ± 2.0 years, 35 boys). Both groups had significantly decreased BMI z-scores from baseline whereas the low-GI group had significant reduction in fasting insulin and HOMA-IR. There were no differences in adipokines between the groups before and after the intervention. However, there was an association between baseline leptin and the change of fat mass index (FMI) but not the insulin resistance in both groups. The higher the baseline leptin was, the lower the changes were for FMI after the intervention. CONCLUSION: Despite no demonstrable effect of low-GI diet on plasma adipokines, the higher baseline leptin was correlated with lower reduction of fat mass. Leptin resistance may have a detrimental effect on the reduction of adiposity in obese children. Baseline leptin could be a useful predictor of the change in body composition in an obesity intervention trial. IMPACT: Leptin resistance may have a detrimental effect in reducing the adiposity in obese children. This study is the first of its kind to compare the plasma adipokine concentrations of obese children on low-GI diet and conventional diet. We found that serum leptin was significantly correlated with the reduction of BMI z-score and FMI in both groups. Baseline leptin could be a useful predictor of the change in body composition in an obesity intervention trial.

Growth and nutritional status of pediatric patients treated with the ketogenic diet.

BACKGROUND AND OBJECTIVES: Ketogenic diet (KD), a well-known nonpharmacologic treatment of intractable epilepsy, could adversely affect growth and nutritional status; however, such data are limited in Thailand. This study aimed to assess growth and nutritional status of Thai children treated with KD together with dietary adherence and its related factors. METHODS AND STUDY DESIGN: The records of children treated with KD for more than 1 month between January 2009 to September 2020 were reviewed. Weight, height, and biochemical indices were retrieved at baseline, 1, 3, 6, 12, 18, and 24 months. Type of KDs, compliance and adverse effects were extracted. RESULTS: Forty-eight patients (21 male) were enrolled. Median age was 3.5 years (IQR 0.9, 10.1). There was no significant decrease in weight-for-age z-score (WAZ) despite a trend toward minimal reduction in WAZ at 3 months. Median follow-up time was 13 months (IQR 7, 29.5). Height-for-age z-score (HAZ) significantly decreased at 12 months [median -1.55 (IQR -3.35, -0.43) vs baseline median -0.6 (IQR -2.07, 0.29)]. Adherence of KD in tube feeding patients was better than oral feeding. Thirty seven percent (18/48) of the patients continued the diet beyond 2 years. Early discontinuation before 6 months was mostly due to poor compliance from patients and families (6/11, 55%). Common adverse effects were GI problems (77%), dyslipidemia (64%) and hypercalciuria (29%). CONCLUSIONS: Under close monitoring, KD can be administered in Thai children with minimal adverse effects on growth and nutritional status. Adherence depends on route of feeding, clinical response, and cooperation of the families.

Effectiveness of Medium Chain Triglyceride Ketogenic Diet in Thai Children with Intractable Epilepsy.

OBJECTIVE: To determine the efficacy, side effects and feasibility of Medium chain triglyceride (MCT) ketogenic diet (KD) in Thai children with intractable epilepsy. MATERIAL AND METHOD: Children with intractable epilepsy were recruited. Baseline seizure frequency was recorded over 4 weeks before starting MCT KD. Average seizure frequency was assessed at 1 month and 3 months, compared to the baseline using Wilcoxon Signed Rank Test. Side effects and feasibility were also assessed by blood tests and an interview. RESULTS: Sixteen subjects were recruited with mean seizure frequency of 0.35-52.5 per day. After treatment, there was a significant reduction in seizure frequency, ranging from 12% to 100% (p = 0.002 at 1 month, and 0.001 at 3 months). 64.3% of the subjects achieved more than 50% seizure reduction at 3 months and 28.6% of the patients were seizure-free. Common adverse effects were initial weight loss (37.5%) and nausea (25%). 87.5% of subjects and parents were satisfied with the MCT KD with 2 cases dropping-out due to diarrhea and non-compliance. CONCLUSION: MCT ketogenic diet is effective and feasible in Thai children with intractable epilepsy. Despite modification against Asian culinary culture, the tolerability and maintenance rate was still satisfactory. A larger study is required.

Resting Energy Expenditure Measured by Indirect Calorimetry in Infants and Young Children with Chronic Lung Disease.

Objective: To determine resting energy expenditure (REE) by indirect calorimetry and to compare measured resting energy expenditure (mREE) by indirect calorimetry with prediction equations (pREE). Material and Method: Infants and young children with chronic lung diseases from King Chulalongkorn Memorial Hospital were enrolled and assessed for nutritional status and severity of chronic lung diseases. For mREE, indirect calorimetry was performed by custom-made airtight canopy with O2 and CO2 sensors, with the patients were in a resting state. Prediction equations were Food and Agriculture/World Health Organization/United Nations University (FAO/WHO/UNU), Schofield-Weight, Schofield-Weight/Height, Harris Benedict, and Harris Benedict-Infant equations. Agreement between mREE and pREE was assessed by Bland-Altman method. Results: Eighteen patients (median age 6 months, range 1 to 26 months) were recruited. Sixteen children had weight for age Z-score below -2 SD. Median weight for age Z-score, length for age Z-score and weight for length Z-score were -3.0, -3.1, and -1.9, respectively. Median mREE was 53.8 kcal/kg/day (interquartile range 47.5 to 72.6 kcal/kg/day). The Schofield-Weight/Height equation showed the lowest mean of difference at 0.94 kcal/kg/day with 95% confidence interval for the bias -44.4 to 46.3 kcal/kg/day. Conclusion: To ensure optimal nutritional support, REE should be measured by indirect calorimetry in pediatric patients with chronic lung diseases. Based on our finding, the Schofield-Weight/Height equation was the most accurate equation for predicting REE in this group of patients.

Low-glycemic index diet may improve insulin sensitivity in obese children.

BACKGROUND: A low-glycemic index (GI) diet may be beneficial for weight management due to its effect on insulin metabolism and satiety. METHODS: Obese children aged 9-16 y were randomly assigned either a low-GI diet or a low-fat diet (control group) for 6 mo. Body composition changes were measured by dual-energy X-ray absorptiometry and bioelectrical impedance analysis. Insulin sensitivity was measured by fasting plasma glucose and insulin. RESULTS: Fifty-two participants completed the study (mean age: 12.0 ± 2.0 y, 35 boys); both groups showed significantly decreased BMI z-score but similar changes in fat and fat-free mass. The low-GI group demonstrated a significant decline in fasting plasma insulin (22.2 ± 14.3 to 13.7 ± 10.9 mU/l; P = 0.004) and homeostatic model of assessment-insulin resistance (4.8 ± 3.3 to 2.9 ± 2.3; P = 0.007), whereas the control group did not. However, general linear model showed no significant difference in insulin resistance between groups after adjusting for baseline levels, suggesting that the greater reduction in insulin resistance in the low-GI group may be explained by higher baseline values. CONCLUSION: Despite subtle effects on body composition, a low-GI diet may improve insulin sensitivity in obese children with high baseline insulin. A bigger study in obese children with insulin resistance could be worthwhile to confirm our findings.

Composition of Follow-Up Formula for Young Children Aged 12-36 Months: Recommendations of an International Expert Group Coordinated by the Nutrition Association of Thailand and the Early Nutrition Academy.

BACKGROUND: There are no internationally agreed recommendations on compositional requirements of follow-up formula for young children (FUF-YC) aged 1-3 years. AIM: The aim of the study is to propose international compositional recommendations for FUF-YC. METHODS: Compositional recommendations for FUF-YC were devised by expert consensus based on a detailed literature review of nutrient intakes and unmet needs in children aged 12-36 months. RESULTS AND CONCLUSIONS: Problematic nutrients with often inadequate intakes are the vitamins A, D, B12, C and folate, calcium, iron, iodine and zinc. If used, FUF-YC should be fed along with an age-appropriate mixed diet, usually contributing 1-2 cups (200-400 ml) of FUF-YC daily (approximately 15% of total energy intake). Protein from cow's milk-based formula should provide 1.6-2.7 g/100 kcal. Fat content should be 4.4-6.0 g/100 kcal. Carbohydrate should contribute 9-14 g/100 kcal with >50% from lactose. If other sugars are added, they should not exceed 10% of total carbohydrates. Calcium should provide 200 mg/100 kcal. Other micronutrient contents/100 kcal should reach 15% of the World Health Organization/Food and Agriculture Organization recommended nutrient intake values. A guidance upper level that was 3-5 times of the minimum level was established. Countries may adapt compositional requirements, considering recommended nutrient intakes, habitual diets, nutritional status and existence of micronutrient programs to ensure adequacy while preventing excessive intakes.

Effect of a low-carbohydrate diet on respiratory quotient of infants with chronic lung disease.

OBJECTIVE: To compare the respiratory quotient in infants with chronic lung disease before and after receiving a modular diet with slightly lower carbohydrate content. MATERIAL AND METHOD: Infants with chronic lung disease from the King Chulalongkorn Memorial Hospital were enrolled and assessed for nutritional status, severity of chronic lung disease and dietary intake. Indirect calorimetry was performed using a custom-made airtight canopy with O2 and CO2 sensors. Respiratory quotient (RQ) was calculated from VCO2/VO2 during the period they were fed low carbohydrates (37% of total calories) for at least 24 hours vs. a standard diet (47% carbohydrate). These two formulas were similar in terms of caloric density and protein content. Each patient received at least 100-150 kcal/ kg/day during the study period. Respiratory quotients of the same patient receiving the two diets were compared by using Wilcoxon signed-rank test. RESULTS: A total of 14 patients (median age 7 months, range 1-26 months) were recruited. Twelve children had weight for age Z-score below-2SD. Their median weight for age Z-score, length for age Z-score and weight for length Z-score were -2.89, -3.08 and -1.24, respectively. The median RQ measured during the low carbohydrate diet was 0.96 (interquartile range 0.95-0.97), significantly lower than the median RQ during the standard diet, which was 1.04 (0.97-1.10). However, the respiratory rate revealed no significant difference. Two participants with underlying gastroesophageal reflux disease showed higher RQ after low carbohydrate formula feeding, which might be a result of hypersecretion due to its high fat content. CONCLUSION: Diet with slightly lower carbohydrate content can reduce the RQ in infants with chronic lung disease compared to the standard enteral formula. A 10-percent reduction of carbohydrate content may provide a sizeable effect in this group of patients. Nevertheless, the clinical significance of this finding requires further investigation.

Effect of folic acid supplementation on plasma homocysteine in obese children: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Obese children tend to consume less dietary folate, which is an important cofactor in remethylation of homocysteine to methionine. The deficiency of folate can lead to hyperhomocysteinemia. OBJECTIVE: To determine whether folic acid supplementation could reduce plasma homocysteine in obese children. MATERIAL AND METHOD: Obese children, aged 9-15 years with body mass index > median plus 2 SD according to WHO reference, were randomly assigned to 2 groups: receiving either 5 mg folic acid or placebo for 2 months. Fasting homocysteine, creatinine, folate, vitamin B12, insulin, glucose and lipid profiles were taken at baseline and the end of the study. Dietary vitamin B12, folate intake and physical activity were assessed using validated questionnaires. RESULTS: Fifty obese children (31 boys and 19 girls) took part in the study. Their mean age was 10.9 ± 1.6 years and mean BMI Z-score was 3.41 ± 0.69. After the intervention, plasma homocysteine decreased by 15.75% and 6.99% in the folic acid and placebo group, respectively (mean difference 8.76%; 95% CI: 0.26%, 17.25%, p = 0.044). This divergence was more pronounced in boys and it remained significant after adjusting for baseline homocysteine and other confounders. Subgroup analysis showed a larger magnitude of plasma homocysteine reduction in the low folate group (mean difference 12.24%; 95% CI: 1.39%, 23.09%). CONCLUSION: The homocysteine lowering effect of folic acid supplementation was found in obese children, especially in boys and those with low serum folate. Further long-term interventional studies are needed to determine the effects of the lowered plasma homocysteine on the cardiovascular outcomes of obese children. This trial was registered on clinicaltrials.gov (NCT01766310).

Inulin supplementation exhibits increased muscle mass via gut-muscle axis in children with obesity: double evidence from clinical and in vitro studies.

Gut microbiota manipulation may reverse metabolic abnormalities in obesity. Our previous studies demonstrated that inulin supplementation significantly promoted Bifidobacterium and fat-free mass in obese children. We aimed to study gut-muscle axis from inulin supplementation in these children. In clinical phase, the plasma samples from 46 participants aged 7-15 years, were analyzed for muscle biomarkers before and after 6-month inulin supplementation. In parallel, the plausible mechanism of muscle production via gut-muscle axis was examined using macrophage cell line. Bifidobacterium was cultured in semi-refined medium with inulin used in the clinical phase. Cell-free supernatant was collected and used in lipopolysaccharide (LPS)-induced macrophage cell line to determine inflammatory and anti-inflammatory gene expression. In clinical phase, IL-15 and creatinine/cystatin C ratio significantly increased from baseline to the 6th month. In vitro study showed that metabolites derived from Bifidobacterium capable of utilizing inulin contained the abundance of SCFAs. In the presence of LPS, treatment from Bifidobacterium + inulin downregulated TNF-α, IL-6, IL-1ß, and iNOS, but upregulated FIZZ-1 and TGF-ß expression. Inulin supplementation promoted the muscle biomarkers in agreement with fat-free mass gain, elucidating by Bifidobacterium metabolites derived from inulin digestion showed in vitro anti-inflammatory activity and decreased systemic pro-inflammation, thus promoting muscle production via gut-muscle axis response.Clinical Trial Registry number: NCT03968003.

Preservation of Anti-SARS-CoV-2 Neutralizing Antibodies in Breast Milk: Impact of Maternal COVID-19 Vaccination and Infection.

Objectives: To investigate specific immunoglobulin A (sIgA), specific immunoglobulin G (sIgG), and neutralizing antibodies (NAbs) against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in breast milk and compare immunity in mothers with hybrid immunity (infection and vaccination) versus those solely vaccinated (coronavirus disease [COVID]-naïve). Methods: A longitudinal study was conducted among lactating mothers who received at least two doses of the coronavirus disease 2019 (COVID-19) vaccine or tested positive for SARS-CoV-2. Details of vaccination and infection were collected through questionnaires and interviews. Fifteen milliliters of breast milk samples, self-collected at 1, 3, and 6 months postvaccination or infection, were sent to analysis for sIgA, sIgG, and NAbs using enzyme-linked immunosorbent assay. Results: In total, 119 lactating mothers (202 milk samples) were enrolled; 82 participants had hybrid immunity, and 32 were COVID-19-naïve. Two-thirds received a combination of different vaccines and booster shots. Breast milk retained sIgA, sIgG, and NAbs for up to 6 months post-COVID vaccination or infection. At 3 months, mothers with hybrid immunity had significantly higher sIgA and NAbs compared with COVID-naïve mothers (geometric mean [95% confidence interval (CI)] of sIgA 2.72 [1.94-3.8] vs. 1.44 [0.83-2.48]; NAbs 86.83 [84.9-88.8] vs. 81.28 [76.02-86.9]). No differences in sIgA, sIgG, and NAbs were observed between lactating mothers receiving two, three, or more than or equal to three doses, regardless of hybrid immunity or COVID-naïve status. Conclusion: sIgA, sIgG, and NAbs against SARS-CoV-2 in breast milk sustained for up to 6 months postimmunization and infection. Higher immunity was found in mothers with hybrid immunity. These transferred immunities confirm in vitro protection, supporting the safety of breastfeeding during and after COVID-19 vaccination or infection.

Feeding Difficulties and Feeding Behaviors of Thai Children with Cow's Milk Protein Allergy.

Background: Cow's milk protein allergy (CMPA) is a common food allergy in infants and young children and may be a risk factor for feeding difficulties. Studies exploring feeding difficulties and feeding behaviors in Thai children with CMPA are scarce. Objectives: To determine the prevalence of feeding difficulties and feeding behaviors in Thai children with CMPA compared to healthy controls. Methods: A cross-sectional study was performed comparing children aged 1-6 years old diagnosed with CMPA and had eliminated cow's milk for at least 4 months with age-matched healthy children. Feeding difficulties were evaluated using the Montreal Children's Hospital Feeding Scale questionnaire, and feeding behaviors were measured using the Child Eating Behavior Questionnaire (CEBQ). Results: One hundred and twenty-two participants were recruited (30 children with CMPA and 92 controls). The median age of the CMPA and control groups was 31.0 (14.0, 43.3) and 40.0 (28.0, 53.8) months, respectively (p value = 0.01). The CMPA group had lower calcium, phosphorus, and zinc intake than the healthy controls. The prevalence of feeding difficulties between the two groups did not show a significant difference (36.7 vs. 43.5%, p value = 0.70). The slowness in the eating subscale of feeding behaviors exhibited a lower score in the CMPA group than in the healthy group. Feeding difficulties was positively correlated with the desire to drink (ß 3.079, p value = 0.011) but negatively correlated with the enjoyment of food subscale of CEBQ among the CMPA children (ß -10.684, p value < 0.001). Conclusion: Despite a similar prevalence of feeding difficulties between CMPA and healthy children, the CMPA group demonstrated some differences in feeding behaviors. The lower score of enjoyment of food and a higher score of desire to drink correlated with a higher degree of feeding difficulties in the CMPA children. The provision of appropriate nutrition for this group of children should be prioritized.

The Persistence of Specific Immunoglobulin A Against SARS-CoV-2 in Human Milk After Maternal COVID-19 Vaccination.

Objectives: To investigate SARS-CoV-2 specific immunoglobulin A (sIgA) in breast milk of Thai mothers post COVID-19 vaccination and/or SARS-CoV-2 infection, and to compare the sIgA among lactating mothers with varying COVID-19 vaccination regimes. Materials and Methods: A longitudinal study was conducted in lactating mothers receiving ≥2 doses of COVID-19 vaccine or confirming SARS-CoV-2-positive test as a part of an infant feeding survey. Vaccination and infection details were collected through questionnaires and interviews. Self-collected breast milk samples (30 mL) at 1, 3, and 6 months postvaccination or infection were analyzed for sIgA through enzyme-linked immunosorbent assay (ELISA). Results: Eighty-eight lactating mothers (152 milk samples), average age of 30.7 ± 6.2 years, were recruited. Fifty-five percent of milk samples were from lactating mothers with both SARS-CoV-2 infection and vaccination (hybrid immunity); 40% were from those with vaccination alone (COVID naïve). Sixty percent of lactating mothers received mixed types of vaccines. Median sIgA ratio in breast milk was 2.67 (0.82-7.85). Breast milk sIgA at 1, 3, and 6 months were higher in mothers with hybrid immunity than in COVID naïve (geometric mean [95% confidence interval]: 3.30 [2.06-5.29] versus 1.04 [0.52-2.04], 3.39 [2.24-5.13] versus 1.26 [0.77-2.06], 4.29 [3.04-6.06] versus 1.33 [0.74-2.42], respectively). No significant differences were observed among various vaccination regimes. Conclusion: sIgA against SARS-CoV-2 was detected in breast milk for up to 6 months after immunization together with infection at a greater level than after immunization or infection alone. This immunity could be transferred and protective against SARS-CoV-2 infection. Discontinuation of breastfeeding among mothers who received COVID vaccination or experienced infection should be discouraged. Clinical Trial Registration number: TCTR20220215012.

Outcomes of parenteral vs enteral ketogenic diet in pediatric super-refractory status epilepticus.

BACKGROUND: Super-refractory status epilepticus (SRSE) is extremely difficult to control and associated with poor outcomes. Ketogenic diet (KD) has been increasingly used for SRSE treatment. Enteral ketosis induction in SRSE is sometimes unfeasible, leading to the use of parenteral KD which has limited data among children. OBJECTIVES: To assess the effectiveness of KD and compare parenteral and enteral ketosis induction as treatment options in pediatric SRSE patients. METHODS: This study is a retrospective medical record review of children < 15 years old diagnosed with SRSE who received KD as one of the treatment modalities during 2007-2021 at King Chulalongkorn Memorial Hospital, Thailand. RESULTS: KD was used in 14 (77.8%) of the 18 pediatric SRSE cases whose age ranged from 2 months to 13.5 years. The leading etiologies of SRSE were immune-mediated encephalitis, infectious encephalitis, and epilepsy. Ketosis was induced via enteral route (kEN) in 8/14 and parenteral route (kPN) in 6/14 cases. The median time from the onset of SRSE to KD initiation was 6 days (IQR 4.8-9.3) with no demonstrable difference between groups. The median time to achieve significant ketosis was significantly shorter in the kPN (2 days; IQR 1.8-4) compared to the kEN group (5 days (3.3-7.8)). Nonetheless, the median time after ketosis induction to SRSE termination when anesthetic infusion was stopped was not statistically difference between the kPN (14 days; IQR 8.5-18) and the kEN group (10.5 days (5.5-15.3)). Hypertriglyceridemia was found more in the kPN (6/6, 100%) compared to the kEN group (3/8, 37.5%). All survivors (12/14) were seizure free at discharge. CONCLUSION: Parenteral ketosis induction achieved the target ketosis quicker than enteral induction but showed no difference in efficacy and duration for SRSE termination in our study. The adverse effects were minimal and controllable. Both parenteral and enteral KD could be considered early during SRSE treatment.

Copper-histidine therapy in an infant with novel splice-site variant in the ATP7A gene of Menkes disease: the first experience in South East Asia and literature review.

Menkes disease (MD) is an X linked recessive multi-systemic disorder of copper metabolism, resulting from an ATP7A gene mutation. We report a male infant aged 4 months who presented with kinky hair, hypopigmented skin, epilepsy and delayed development. Magnetic resonance imaging (MRI) of brain demonstrated multiple tortuosities of intracranial vessels and brain atrophy. Investigation had showed markedly decreased serum copper and ceruloplasmin. The novel c.2172+1G>T splice-site mutation in the ATP7A gene confirmed MD. He was treated with subcutaneous administration of locally prepared copper-histidine (Cu-His). Following the therapy, hair manifestation was restored and serum ceruloplasmin was normalised 1 month later. Despite the treatment, epilepsy, neurodevelopment and osteoporosis still progressed. He died from severe respiratory tract infection at the age of 9.5 months. These findings suggest that the benefit of Cu-His in our case is limited which might be related to severe presentations and degree of ATP7A mutation.

Achievement of nutritional goals after a pediatric intensive care unit nutrition support guideline implementation.

BACKGROUND AND AIMS: A nutrition support guideline was developed and implemented in a pediatric intensive care unit (PICU) to improve the nutritional management of patients. This study aimed to evaluate the impact of this guideline on achieving energy and protein delivery goals. METHODS: Medical records of the patients admitted in the PICU from August 2015 to April 2017 were retrospectively reviewed. Patients who stayed in the PICU for less than 24 h or had an inborn error of metabolism were excluded. Achievement of nutritional goals was compared between the patients during the pre-implementation period (August to October 2015) and post-implementation period (November 2015 to April 2017) of the guideline. Subgroup analysis by protocol compliance was conducted in the post-implementation group. RESULTS: A total of 215 patients were included in the study (53 pre-implementation, 162 post-implementation). There were no differences between the two groups in patient characteristics, time to start enteral nutrition, time to reach the energy delivery goal, time to reach the protein delivery goal, and proportion of the patients who reached each goal. In the post-implementation group, parenteral nutrition was delayed to three days compared with one day in pre-implementation (p = 0.027) and the proportion of patients who did not receive nutrition support was lower (3.1% vs 9.4% pre-implementation, p = 0.043). Subgroup analysis in the post-implementation group showed that 69.7% of the patients were protocol compliant, of which the time to reach the energy delivery goal (59 vs 103 h, p < 0.001) and protein delivery goal (64 vs 135 h, p = 0.02) were significantly shorter compared with the non-compliant group. Moreover, the proportion of the patients who reached the energy delivery goal (75.2% vs 24.5%, p < 0.001) and protein delivery goal (56.6% vs 12.2%, p < 0.001) were higher in the compliant group. CONCLUSIONS: Compliance with the nutrition support guideline significantly improved the achievements in delivering energy and protein to patients in PICU. Increasing compliance with the guideline may improve clinical outcomes in PICU patients.

Optimal Enteral Nutrition Support Preserved Muscle Mass in Critically Ill Children.

BACKGROUND: Inflammation and immobility are the most relevant mechanisms that alter protein synthesis and increase protein breakdown. Protein catabolism is associated with morbidity and mortality in critically ill children. OBJECTIVE: To demonstrate the effectiveness of the routinely used enteral nutrition support guideline in preventing muscle breakdown in critically ill children. METHODS: A prospective cohort study was conducted in the pediatric intensive care unit (PICU) of a tertiary care hospital. Critically ill children (aged 1 month to 15 years) admitted to the PICU were enrolled. All patients were assessed for nutritional status and nutritional requirement. Enteral nutrition support following the guideline was initiated within the first 24 hours if no contraindication. The calorie target was defined either by direct measurement from indirect calorimetry or estimated from Schofield equation with protein target at least 1.5 g/kg/day. Anthropometric assessments and body composition measurements by bioelectrical impedance analysis (BIA) were examined at baseline and on the seventh day of the PICU admission. RESULTS: Sixty-three patients were enrolled in the study. The most common age group was 1-5 years old (38.1%). The length of PICU stay was 9.1 (SD = 12.7) days. Respiratory problems were the major cause of PICU admission (50.8%). Mechanical ventilation was required in 55.6% of the patients with the average duration of 6.3 (SD = 12.4) days. Undernutrition was found in 36.5% of the patients. Enteral feeding was the major route of nutrition support (95.2%). After the first week of admission, muscle mass was significantly preserved (p < 0.01). All patients received the nutrition support at their target energy and protein goal within the first week. The enteral feeding-related complication was reported in 1.6% of the patients. CONCLUSION: Protein catabolism during critically ill period can be minimized by optimal nutrition support. Nutrition practice using the enteral nutrition support guideline was effective in helping critically ill children reach their target caloric and protein intake.

Glycemic index and glycemic load of common fruit juices in Thailand.

BACKGROUND: The glycemic index (GI) reflects body responses to different carbohydrate-rich foods. Generally, it cannot be simply predicted from the composition of the food but needs in vivo testing. METHODS: Healthy adult volunteers with normal body mass index were recruited. Each volunteer was asked to participate in the study center twice in the first week to consume the reference glucose (50 g) and once a week thereafter to consume the study fruit juices in a random order. The study fruit juices were Florida orange juice, Tangerine orange juice, Blackcurrant mixed juice, and Veggie V9 orange carrot juice which were already available on the market. The serving size of each fruit juice was calculated to provide 50 g of glycemic carbohydrate. The fasting and subsequent venous blood samplings were obtained through the indwelling venous catheters at 0, 15, 30, 45, 60, 90, and 120 min after the test drink consumption and immediately sent for plasma glucose and insulin. GI and insulin indices were calculated from the incremental area under the curve of postprandial glucose of the test drink divided by the reference drink. Glycemic load (GL) was calculated from the GI multiplied by carbohydrate content in the serving size. RESULTS: A total of 12 volunteers participated in the study. Plasma glucose and insulin peaked at 30 min after the drink was consumed, and then started to decline at 120 min. Tangerine orange juice had the lowest GI (34.1 ± 18.7) and GL (8.1 g). Veggie V9 had the highest GI (69.6 ± 43.3) but it was in the third GL rank (12.4 g). The insulin responses correlated well with the GI. Fructose to glucose ratio was inversely associated with GI and insulin responses for all study fruit juices. Fiber contents in the study juices did not correlate with glycemic and insulin indices. CONCLUSIONS: The GIs of fruit juices were varied but consistently showed a positive correlation with insulin indices. Fruit juices with low GI are a healthier choice for people with diabetes as well as individuals who want to stay healthy since it produces more subtle postprandial glucose and insulin responses.

The Impact of Dietary Fiber as a Prebiotic on Inflammation in Children with Obesity.

Background: Obesity is associated with dysbiosis, contributing to inflammation and insulin resistance. Inulin might reduce inflammation by manipulating intestinal microbiota. Objective: We aimed to determine the effects of inulin supplementation on inflammation and assess the relationships of inflammatory cytokines with adiposity and insulin resistance in obese Thai children. Design: Obese Thai children ages 7−15 years were randomly assigned to inulin (intervention), maltodextrin (placebo), and dietary fiber advice groups. All participants received monthly follow-up and identical advice on lifestyle modification for six visits. Body composition was evaluated using bioelectrical impedance analysis. IL-1ß, IL-6, TNF-α, and fecal calprotectin were analyzed by ELISA technique at baseline and the final visit. Spearman correlation was used to assess the associations between inflammation and other clinical outcome variables. Results: A total of 155 obese children completed the study (mean age: 10.4 ± 2.2 years, 59% male). All groups showed a significant decrease in BMI z-score, fat mass index (FMI), percent body fat, and trunk FMI. A generalized estimating equation (GEE) model showed significantly decreased IL-1ß and TNF-α of 34.8% and 25.8%, (p < 0.0001) but increased IL-6 (21.5%, p = 0.006) in all groups. There were no significant differences in inflammatory cytokines and fecal calprotectin between groups. Mean IL-6 was higher in obese children with acanthosis nigricans (p = 0.048). Only IL-6 was positively correlated with body fat percentage and FMI (r = 0.29, p = 0.008 and r = 0.25, p = 0.049, respectively). Conclusions: Intensive behavioral modification and frequent follow-up visits were effective methods to reduce BMI and adiposity leading to decreased inflammatory cytokines. The additional benefits of inulin on inflammation could not be demonstrated due to the Hawthorne effect. Among the three cytokines, IL-6 was the most likely mediator relating FM and insulin resistance at baseline; therefore, it could be used as a surrogate marker of inflammation in obese children who are at risk for insulin resistance and metabolic syndrome.

Association of Human Intestinal Microbiota with Lifestyle Activity, Adiposity, and Metabolic Profiles in Thai Children with Obesity.

Background: Dysbiosis of intestinal microbiota may be linked to pathogenesis of obesity and metabolic disorders. Objective: This study compared the gut microbiome of obese Thai children with that of healthy controls and examined their relationships with host lifestyle, adiposity, and metabolic profiles. Methods: This cross-sectional study enrolled obese children aged 7-15. Body composition was evaluated using bioelectrical impedance analysis. Stool samples were analyzed by 16S rRNA sequencing using the Illumina MiSeq platform. Relative abundance and alpha- and beta-diversity were compared with normal-weight Thai children from a previous publication using Wilcoxon rank-sum test and ANOSIM. Relationships of gut microbiota with lifestyle activity, body composition, and metabolic profiles were assessed by canonical correlation analysis (CCA) and Spearman correlation. Results: The study enrolled 164 obese children with a male percentage of 59%. Mean age was 10.4 ± 2.2 years with a BMI z-score of 3.2 ± 1. The abundance of Bacteroidetes and Actinobacteria were found to be lower in obese children compared to nonobese children. Alpha-diversity indices showed no differences between groups, while beta-diversity revealed significant differences in the family and genus levels. CCA revealed significant correlations of the relative abundance of gut microbial phyla with sedentary lifestyle and certain metabolic markers. Univariate analysis revealed that Actinobacteria and Bifidobacterium were positively correlated with HDL-C and negatively correlated with body weight and screen time. Additionally, Actinobacteria was also negatively associated with fasting insulin and HOMA-IR. Lactobacillus showed positive correlation with acanthosis nigricans and adiposity. Cooccurrence analysis revealed 90 significant bacterial copresence and mutual exclusion interactions among 43 genera in obese children, whereas only 2 significant cooccurrences were found in nonobese children. Conclusions: The composition and diversity of gut microbiota in obese Thai children were different from those of their normal-weight peers. Specific gut microbiota were associated with lifestyle, adiposity, and metabolic features in obese children. An interventional study is needed to support causality between specific gut microbiota and obesity.