Prolonged Jaundice in a Premature Breastfed Infant With Gilbert's Syndrome.

INTRODUCTION: Neonatal jaundice and prematurity pose significant barriers to breastfeeding in the first days of life. There is limited literature exploring the relationship between prolonged jaundice in breastfed infants and Gilbert's (Meulengraght) syndrome. This case study describes the diagnostic and therapeutic challenges associated with Gilbert's syndrome in a late preterm breastfed infant born in Germany. MAIN ISSUE: In this case report, an infant born to a primipara woman presented at 3 weeks postpartum to an International Board Certified Lactation Consultant. The initial assessment revealed a late preterm infant with inadequate weight gain and jaundice. The dyad received breastfeeding support and eventually achieved adequate weight gain; however, the infant's jaundice persisted. MANAGEMENT: The consulting midwife suggested that the persistent jaundice was "breastmilk jaundice" and recommended temporarily interrupting breastfeeding. Due to a suspected family history of Gilbert's Syndrome, the dyad was referred, instead, to a pediatric gastroenterologist. Pathologic liver disease was excluded, and genetic testing confirmed Gilbert's Syndrome. At 6 months of age, the dyad was successfully breastfeeding and beginning complementary feeding. CONCLUSION: Genetic testing for Gilbert's Syndrome should be considered for infants with prolonged jaundice and positive family history. Interruption or cessation of breastfeeding are not evidence-based recommendations, and current guidelines do not support these practices. Lactation professionals play a critical role in the management of breastfeeding for preterm infants with prolonged jaundice and should refer to specialists to rule out pathologic etiologies.

National survey of infant feeding bottles in Germany: Their characteristics and marketing claims.

Bottles and teats are ubiquitously used for feeding infants and young children. Yet there are limited empirical studies on the scope of infant feeding bottles, their attributes, or their marketing claims. We report the first comprehensive survey on infant feeding bottles and teats in Germany. We aimed to explore the extent of bottles and teats available in Germany, describe their physical attributes and analyze their marketing claims. A cross-sectional survey of German bottle and teat manufacturer websites was conducted between June and November 2022. Product attributes are presented with descriptive statistics and photographs. Marketing claims are summarized in a descriptive content analysis. We identified 41 brands encompassing 447 unique products (226 bottles, 221 teats). The majority of bottles were plastic (147, 65%) or glass (64, 28%), and the majority of teats were silicone (188, 85%). Most brands (38, 93%) promoted products using one or more inappropriate marketing claims, including equivalency to breastfeeding (29, 73%), idealization through technical or medical descriptions (23, 58%), claims on disease prevention (31, 78%), references to naturalness (29, 73%), infant autonomy (10, 25%), and endorsements from parents (10, 25%) or health professionals (11, 28%). The majority of bottles and teats available in Germany appear to be marketed inappropriately and hold the potential to undermine public health recommendations on infant and young child feeding. Therefore, we recommend Germany strengthens legislation on the marketing of bottles and teats in accordance with the International Code of Marketing of Breastmilk Substitutes.

Quality of systematic reviews on timing of complementary feeding for early childhood allergy prevention.

BACKGROUND: Only rigorously prepared analyses can provide the highest level of evidence to inform decision-making. Several recent systematic reviews (SRs) examined the hypothesis that the early introduction of specific allergenic complementary foods (CFs) to infants may lead to a lower incidence of one or more allergic outcomes. However, the methodological rigour and quality of reporting of SRs in this area has not yet been systematically evaluated. METHODS: We comprehensively searched PubMed, Medline (Ovid), and Web of Science Core Collection on 13th January 2022, using a pre-specified and tested search syntax for SRs with RCT evidence on the early introduction of allergenic CFs as a means for allergy prevention in infants and children. We examined the quality and risk of bias (RoB) using AMSTAR-2 and ROBIS tools, examined adherence to the Preferred Reporting Items for SRs and Meta-Analyses (PRISMA), and checked whether certainty of the evidence was assessed. RESULTS: Twelve SRs were included. Application of both tools resulted in similar overall judgements in terms of direction and extent for nine of the 12 SRs. Nine SRs were found to be of critically low to low quality according to AMSTAR-2 and to be at high RoB according to ROBIS. One SR received a moderate quality rating (AMSTAR-2) and high RoB rating (ROBIS). However, for two SRs, judgements between AMSTAR-2 and ROBIS were at stark variance. Only two SRs fully adhered to the PRISMA checklist. Six SRs evaluated the certainty of the body of RCT evidence. Several SRs failed to consider unpublished studies either by an explicit a priori exclusion or by inadequate search strategies. CONCLUSIONS: Well-conducted SRs are important for decision-making and informing guideline development, the quality of their methodology should therefore be considered. The methodological rigour and the reporting quality of SRs on the timing of CF for allergy prevention must be improved. REGISTRATION: https://osf.io/7cs4b .

Moving Complementary Feeding Forward: Report on a Workshop of the Federation of International Societies for Pediatric Gastroenterology, Hepatology and Nutrition (FISPGHAN) and the World Health Organization Regional Office for Europe.

The WHO Regional Office for Europe and the Federation of International Societies for Pediatric Gastroenterology, Hepatology, and Nutrition held a joint workshop, "Moving Complementary Feeding Forward" at the sixth World Congress Pediatric Gastroenterology, Hepatology, and Nutrition in 2021. Here we summarize workshop presentations and discussions. The workshop covered health implications of complementary feeding (CF) including allergies, challenges to meet dietary needs during the CF period, quality of commercial complementary foods (CFD) and respective marketing practices, national CF guidelines in Europe, a nutrient profiling system for CFD, and global policy perspectives on the standards and regulation of marketing for CFD. Adequate CF practices are of critical importance for short and long-term child health, prevention of nutrient deficiencies, normal growth and development, and reducing the risk of allergies. The workshop identified the need to improve feeding practices, harmonize evidence-based information and develop guidance jointly with various stakeholders, improve the composition and marketing practices of commercial CFD and their transparent labeling based on nutrient profiling. Renewed efforts for collaboration between scientists, public health experts, pediatric associations, national governments, and the WHO are necessary for advancing progress.

Dietary patterns acquired in early life are associated with cardiometabolic markers at school age.

BACKGROUND & AIMS: it has previously been described that dietary patterns established early in life tracked to late childhood. The aim of the present work was to analyse the association of dietary patterns that tracked from 2 to 8y with cardiometabolic markers at 8y of age. METHODS: The 3 identified patterns at 2y (that previous analyses showed to track to age 8y) were: "CoreDP", loaded for vegetables, fruits, fish, olive oil, etc.; "F&SDP", loaded by poor-quality fats and sugars; and "ProteinDP", mainly loaded by animal protein sources. Cardiometabolic markers at 8y were systolic blood pressure (SBP), insulin resistance (HOMA-IR), and triglycerides, and BMI z-score. To examine whether the association of diet with the outcomes was the result of a direct effect of diet at either two or 8y, or synergy between them, we used structural equation models. RESULTS: the associations between the patterns and the health outcomes were: CoreDP was inversely associated with SBP and HOMA-IR; ProteinDP was directly associated with HOMA-IR and SBP; and adherence to F&SDP was directly associated with triglycerides and SBP. The associations between the patterns and the health outcomes were independent of BMI and were the result of a direct effect of diet at 2y, an indirect effect of diet at 2y through diet at 8y or a combination between both pathways. CONCLUSION: dietary patterns acquired in early life, persisting to later childhood, were associated with cardiometabolic markers at school age independently of BMI.

Supporting breastfeeding of small, sick and preterm neonates.

Breastfeeding is associated with a risk reduction for several acute and chronic diseases in women and their infants. Health benefits of breastfeeding are especially important for small, sick and preterm infants. The objective of this article is to summarize essential steps for healthcare personnel and facilities to improve breastfeeding practices in this vulnerable population. Health facilities can support breastfeeding through the establishment of breastfeeding-supportive policies, staff training and the design of facilities to support rooming-in. Direct support to breastfeeding includes the provision of counseling to mothers at critical time points, skin-to-skin and kangaroo care, and support of responsive (on-demand) breastfeeding. Where direct breastfeeding is not possible, facilities should show mothers how to express their breastmilk and teach mothers alternative feeding modalities. Medically-indicated supplementation of small, sick and preterm may be needed in certain circumstances.

Nutritional Adequacy of Commercial Complementary Cereals in Germany.

Commercial cereals are among the first complementary foods fed to infants in Germany and elsewhere. The purpose of this national survey is to describe the nutritional adequacy of commercial complementary cereals. A comprehensive, cross-sectional survey of cereal manufacturer websites (n = 15) was conducted from March to April 2019. Food labels were analyzed for iron, zinc, iodine, sodium, and sugar contents in commercial complementary cereals, and ingredient lists were evaluated for whole grains and added sugars. Preparation instructions were evaluated for the type of liquid recommended for reconstitution. Among 164 commercial complementary cereals, few contain iron (n = 43, 26%), zinc (n = 23, 14%) or iodine (n = 43, 26%). Sodium contents fall within EU thresholds. Most cereals were single grain, containing only wheat (n = 54), with half of the products (n = 86, 52%) containing whole grains. The average carbohydrate content of dry cereals is 69 g/100 g ± 9 g of which 14 ± 15 g is sugar. Preparation instructions for breakfast porridges and cereals recommend formula or toddler milk, while few recommend human milk (n = 13, 18%). Few commercial complementary cereals contain appreciable amounts (at least 15% of daily reference values) of zinc, iron, or iodine. A quarter of cereal carbohydrates are sugar and one-third of the products contain added sugars. Future directives should stipulate minimum micronutrient levels, strictly regulate sugar contents, and include human milk among preparation instructions.

Commercial complementary food use amongst European infants and children: results from the EU Childhood Obesity Project.

PURPOSE: The objective of this secondary analysis is to describe the types of commercial complementary foods (CCF) consumed by infants and young children enrolled in the European Childhood Obesity Project (CHOP), to describe the contribution of CCF to dietary energy intakes and to determine factors associated with CCF use over the first 2 years of life. METHODS: The CHOP trial is a multicenter intervention trial in Germany, Belgium, Italy, Poland and Spain that tested the effect of varying levels of protein in infant formula on the risk for childhood obesity. Infants were recruited from October 2002 to June 2004. Dietary data on CCF use for this secondary analysis were taken from weighted, 3-day dietary records from 1088 infants at 9 time points over the first 2 years of life. RESULTS: Reported energy intakes from CCF during infancy (4-9 months) was significantly higher (p ≤ 0.002) amongst formula-fed children compared to breastfed children. Sweetened CCF intakes were significantly higher (p ≤ 0.009) amongst formula-fed infants. Female infants were fed significantly less CCF and infant age was strongly associated with daily CCF intakes, peaking at 9 months of age. Infants from families with middle- and high-level of education were fed significantly less quantities of CCF compared to infants with parents with lower education. Sweetened CCF were very common in Spain, Italy and Poland, with over 95% of infants and children fed CCF at 9 and 12 months of age consuming at least one sweetened CCF. At 24 months of age, 68% of the CHOP cohort were still fed CCF. CONCLUSIONS: CCF comprised a substantial part of the diets of this cohort of European infants and young children. The proportion of infants being fed sweetened CCF is concerning. More studies on the quality of commercial complementary foods in Europe are warranted, including market surveys on the saturation of the Western European market with sweetened CCF products.

Food safety considerations for commercial complementary foods from global operational guidance on infant and young child feeding in emergencies.

The use of commercial complementary food (CCF) in humanitarian emergencies is an emerging topic in nutrition policy. Food safety guidance is helpful for the prevention of foodborne illnesses in infants and young children, but whether current global operational guidance on infant and young child feeding in emergencies (IYCF-E) adequately addresses food safety for CCF in humanitarian emergencies is unknown. The aim of this review was to identify and synthesize available food safety guidance on the use of CCF in humanitarian emergencies. A narrative review that included a systematic content analysis and thematic synthesis of global operational guidance on IYCF-E was conducted. Fourteen global guidance documents were selected. Forty-nine excerpts specific to CCF were identified, of which 10 (20%) were rated as relevant to the prevention of foodborne illness. Assessment of inter-rater reliability showed 80% agreement, with a Cohen's kappa coefficient (κ) of 0.52 (moderate agreement). Content was synthesized in 3 themes: donations of CCF, quality assurance and quality control, and water, sanitation, and hygiene principles. Little salient guidance for the safe use of CCF in emergencies was identified. Global operational guidance on IYCF-E should be updated by incorporating food safety considerations for the use of CCF.

Breastfeeding Rates and Programs in Europe: A Survey of 11 National Breastfeeding Committees and Representatives.

INTRODUCTION: Among the world's regions, the WHO European Region has the lowest rates of exclusive breastfeeding at the age of 6 months with approximately 25%. Low rates and early cessation of breastfeeding have important adverse health consequences for women, infants, and young children. Protecting, promoting, and supporting breastfeeding are a public health priority. OBJECTIVES: National breastfeeding data and monitoring systems among selected European countries and the WHO European Region are compared. Mechanisms for the support, protection, and promotion of breastfeeding are reviewed and successes and challenges in implementation of national programs are presented. METHODS: National representatives of national breastfeeding committees and initiatives in 11 European countries, including Belgium, Croatia, Denmark, Germany, Ireland, Italy, The Netherlands, Norway, Spain, Sweden, and Switzerland, participated in a standardized survey. Results are evaluated and compared in a narrative review. RESULTS: Variation exists in Europe on breastfeeding rates; methodology for data collection; and mechanisms for support, protection, and promotion of breastfeeding. Directly after birth, between 56% and 98% of infants in all countries were reported to receive any human milk, and at 6 months 38% to 71% and 13% to 39% of infants to be breastfed or exclusively breastfed, respectively. National plans addressing breastfeeding promotion, protection, and support exist in 6 of the 11 countries. CONCLUSIONS: National governments should commit to evidence-based breastfeeding monitoring and promotion activities, including financial and political support, to improve breastfeeding rates in the Europe. Renewed efforts for collaboration between countries in Europe, including a sustainable platform for information exchange, are needed.

Perspective: Novel Commercial Packaging and Devices for Complementary Feeding.

In recent years, so-called baby food pouches and other novel packaging and devices have been marketed for complementary feeding. To date, no experimental studies have been conducted to determine health and nutrition effects or the safety of baby food pouches and related feeding devices. Yet, these products hold the potential to fundamentally change the ways in which infants and children consume solid foods in infancy and early childhood. In this review, a selection of complementary feeding devices and their potential effects on breastfeeding, formula-feeding, safe and appropriate complementary feeding, and the timely transition to family foods are explored. Because manufacturers have innovated older designs of traditional feeding bottles and pacifiers for complementary feeding, perspectives on potential health effects and the safety of devices are drawn from research on feeding bottles and pacifiers. Recommendations include scaling up research on the safety, nutrition, and health impacts of commercial packaging and devices. In addition, manufacturers should ensure that devices conform to consumer product safety commission specifications and that instructions for use are in line with policies protecting pediatric dental health. Marketing of commercial devices and packaging should conform to the International Code of Marketing of Breastmilk Substitutes.

Complementary Feeding, Infant Growth, and Obesity Risk: Timing, Composition, and Mode of Feeding.

The complementary feeding period is a short transitional period from breastfeeding and formula feeding to family foods. Timing, quantity, and quality are implied to impact growth and obesity risk. We summarized the literature and analyzed data of monthly 3-day food diaries of >1,000 children from 5 European countries in the first 2 years of life, which were collected as part of the prospective European Childhood Obesity Project (CHOP Study). Formula-fed children started complementary food approximately 2 weeks earlier than breastfed children, and almost 40% of them at or before 4 months of age. While introduction of solids between 4 and 6 months or after 6 months does not seem to impact growth and later obesity risk, solids before 4 months of age increased the risk. There are indications that this is especially problematic for formula-fed children. During the complementary feeding period, fat intake decreases, and protein and carbohydrate intakes increase. Protein intake often exceeds European recommendations from 9 months onwards. However, the role of macronutrients during complementary feeding in growth and metabolism needs further clarification. Findings on the role of responsive feeding or baby-led feeding during complementary feeding in growth are not conclusive. In summary, while introduction of complementary foods before 4 months of age should be avoided, the impact of the quality of complementary food on short-term growth and later obesity risk has to be elucidated further.

Predictors of female sexual dysfunction: a systematic review and qualitative analysis through gender inequality paradigms.

BACKGROUND: Female sexual dysfunction affects 41% of reproductive-age women worldwide, making it a highly prevalent medical issue. Predictors of female sexual dysfunction are multifaceted and vary from country to country. A synthesis of potential risk factors and protective factors may aid healthcare practitioners in identifying populations at risk, in addition to revealing modifiable factors to prevent sexual dysfunction among reproductive-age women. METHODS: Observational studies which assessed the prevalence and predictors of female sexual dysfunction in reproductive-age women were systematically sought in relevant databases (2000-2014). Significant predictors were extracted from each included publication. A qualitative analysis of predictors was performed with a focus on types of sexual regimes and level of human development. RESULTS: One hundred thirty-five studies from 41 countries were included in the systematic review. The types of predictors varied according to the location of the study, the type of sexual regime and the level of gender inequality in that country/region. Consistently significant risk factors of female sexual dysfunction were: poor physical health, poor mental health, stress, abortion, genitourinary problems, female genital mutilation, relationship dissatisfaction, sexual abuse, and being religious. Consistently significant protective factors included: older age at marriage, exercising, daily affection, intimate communication, having a positive body image, and sex education. Some factors however had an unclear effect: age, education, employment, parity, being in a relationship, frequency of sexual intercourse, race, alcohol consumption, smoking and masturbation. CONCLUSIONS: The sexual and reproductive lives of women are highly impacted by female sexual dysfunction, and a number of biological, psychological and social factors play a role in the prevalence of sexual dysfunction. Healthcare professionals who work with women should be aware of the many risk factors for reproductive-age women. Future prevention strategies should aim to address modifiable factors, e.g. physical activity and access to sex education; international efforts in empowering women should continue.

[Breastfeeding rate and promotion in selected European countries]. / Stillquoten und Stillförderung in ausgewählten Ländern Europas.

BACKGROUND: Breastfeeding benefits the short- and long-term health of mothers and their children. Breastfeeding promotion is an important task for society and the healthcare system. AIMS: We report national breastfeeding data and monitoring systems of selected European countries based on data provided by national breastfeeding committees and international organisations. Strategies for promoting, protecting and supporting breastfeeding, achievements and challenges are reported. METHODS: Representatives of breastfeeding committees and initiatives from Belgium, Croatia, Denmark, Germany, Italy, Ireland, Norway, Sweden, Switzerland, Spain and The Netherlands completed a standardised questionnaire. Reported results were compiled and complemented by additional information compiled by the authors. RESULTS: Considerable differences in breastfeeding rates, data collection and strategies for breastfeeding promotion exist within Europe. At the age of 6 months 35-65% of infants are breastfed and 13-39% are fully or exclusively breastfed in the countries included. Varying methods of breastfeeding monitoring are established in 7 of 11 countries (not in Germany). National breastfeeding committees exist in 9 countries and a national plan for breastfeeding promotion in 6 countries. All country representatives supported stronger European collaboration on improved breastfeeding promotion. CONCLUSIONS: Governments and health systems should collaborate in strengthening evidence based breastfeeding monitoring and promotion and implement financial and policy support. Sustained enhanced collaboration of European countries with exchange of information and experience on breastfeeding support and a new initiative for establishing a strategic European masterplan on breastfeeding promotion appear necessary.

Are Commercial Complementary Food Distributions to Refugees and Migrants in Europe Conforming to International Policies and Guidelines on Infant and Young Child Feeding in Emergencies?

In 2015, more than one million migrants and refugees arrived in Europe. Commercial complementary foods, processed foods marketed for infants and young children 6-23 months of age, were distributed by various humanitarian actors along migrant routes and in European refugee camps. Unsolicited donations and distributions of commercial complementary food products were problematic and divergent from international policies on infant and young child feeding during humanitarian emergencies. Interim guidance regarding commercial complementary foods was published during the peak of the emergency but implemented differently by various humanitarian actors. Clearer and more technical specifications on commercial complementary foods are needed in order to objectively determine their suitability for operational contexts in Europe and emergency nutrition assistance in the future.

Prevalence of Female Sexual Dysfunction Among Premenopausal Women: A Systematic Review and Meta-Analysis of Observational Studies.

INTRODUCTION: Epidemiologic research in female sexual dysfunction (FSD) has gained momentum in recent years, particularly in clinical populations and in menopausal women. However, sexual dysfunction also affects premenopausal women in general populations. Previous literature reviews have been unable to quantify the burden of FSD in general populations. This has been due in part to different definitions of dysfunction, heterogeneous study design, and the wide variety of measurement tools used. AIM: To provide a meta-analytical estimate of the prevalence of FSD in premenopausal women. METHODS: Observational studies that assessed the prevalence of FSD in premenopausal women were systematically sought in relevant databases (January 2000 through July 2014). Publications that reported the prevalence rate for at least one domain of FSD were included. A meta-analysis of prevalence rates was performed and a meta-regression was used to analyze factors of study design. MAIN OUTCOME MEASURES: Estimated prevalence rates of FSD and its domains (hypoactive sexual desire disorder, sexual aversion disorder, female sexual arousal disorder, lubrication difficulties, female orgasmic disorder, and pain disorders). RESULTS: After screening 9,292 results, 440 publications were retrieved for full-text review. Of these, 135 studies were included in the systematic review. Ninety-five of these studies were assessed further in a meta-analysis. There was substantial heterogeneity among studies. The prevalence of FSD in premenopausal women was estimated to be 40.9% (95% CI = 37.1-44.7, I2 = 99.0%). Prevalence rates of individual sexual disorders ranged from 20.6% (lubrication difficulties) to 28.2% (hypoactive sexual desire disorder). Further analyses showed significantly higher rates of FSD in studies in Africa, studies that used non-validated assessment tools, and studies without pharmaceutical funding. CONCLUSION: Prevalence estimates of FSD vary substantially. Nonetheless, results show that FSD is a significant public health problem that affects 41% of premenopausal women around the globe. More research and improved standardization are needed in this field.