Enhancing gut microbiota and microbial function with inulin supplementation in children with obesity.

BACKGROUND AND OBJECTIVES: Gut dysbiosis that resulted from the alteration between host-microbe interaction might worsen obesity-induced systemic inflammation. Gut microbiota manipulation by supplementation of prebiotic inulin may reverse metabolic abnormalities and improve obesity. This study aimed to determine whether inulin supplementation improved intestinal microbiota and microbial functional pathways in children with obesity. METHODS: Children with obesity whose BMI above median + 2SDs were recruited to a randomized, double-blinded placebo-controlled study. The participants aged 7-15 years were assigned to inulin supplement extracted from Thai Jerusalem artichoke (intervention), maltodextrin (placebo), and dietary fiber advice groups. All participants received similar monthly conventional advice and follow-up for 6 months. Fecal samples were collected for gut microbiome analysis using 16S rRNA sequencing. Phylogenetic Investigation of Communities by Reconstruction of Unobserved States was performed to infer microbial functional pathways. RESULTS: One hundred and forty-three children with available taxonomic and functional pathway abundance profiles were evaluated. A significant increase in alpha-diversity was observed in the inulin group. Inulin supplementation substantially enhanced Bifidobacterium, Blautia, Megasphaera, and several butyrate-producing bacteria, including Agathobacter, Eubacterium coprostanoligenes, and Subdoligranulum, compared to the other groups. The inulin group showed a significant difference in functional pathways of proteasome and riboflavin metabolism. These changes correlated with clinical and metabolic outcomes exclusively in the inulin group. CONCLUSIONS: Inulin supplementation significantly promoted gut bacterial diversity and improved gut microbiota dysbiosis in children with obesity. The modulation of functional pathways by inulin suggests its potential to establish beneficial interactions between the gut microbiota and host physiology. Inulin supplementation could be a strategic treatment to restore the balance of intestinal microbiota and regulate their functions in childhood obesity.

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.

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.

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.

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.

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.

Effects of inulin supplementation on body composition and metabolic outcomes in children with obesity.

Inulin might improve body composition in obese children. We aimed to determine the effects of inulin supplementation on body composition and metabolic outcomes in obese children. A randomized, double-blinded placebo-controlled study was conducted in obese Thai children aged 7-15 years. Participants were assigned to 3 treatment groups for 6 months: 13 g of extracted inulin powder from Thai Jerusalem artichoke, isocaloric maltodextrin, and dietary fiber advice groups. Body composition was assessed by bioelectrical impedance analysis. One-hundred and fifty-five children completed the study (mean age 10.4 ± 2.2 years, BMI z-score 3.2 ± 1.0, 59% male). The drop-out rate was 6%. The inulin extract yielded more than 90% compliance without significant gastrointestinal side effects. All three groups demonstrated a significant decrease in BMI z-score, fat mass index (FMI), and trunk FMI, but the differences between groups were not observed. Fat-free mass index significantly increased only in the inulin group (16.18 ± 1.90 vs. 16.38 ± 1.98 kg/m2, P = 0.009). There were no significant differences in the metabolic profiles between groups. Despite showing no substantial effect on adiposity, inulin may increase fat-free mass in obese children. Further research in the change of gut microbiota composition is needed to determine inulin's impact on host-microbe interaction in pediatric obesity.

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.

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.

Effects of Maternal Exclusion Diet for Infants Suspected Food Allergy on Fatty Acid Composition in Breast Milk.

Background: Levels of fatty acid (FA) in breast milk (BM) may vary depending on the maternal diet. This study aimed to explore FA composition in BM of lactating women following dietary restrictions due to infant allergic conditions. Materials and Methods: Thai lactating mothers of term infants who were on exclusion diets were recruited. Mature BM was collected before and after a period (at least 2 weeks) of dietary restriction. FA in BM was analyzed by gas chromatography-mass spectrometry. Results: Fifty lactating women 33.7 ± 3.6 years of age were enrolled. Thirty-three percent of the lactating mothers restricted more than eight food items. Most common dietary restriction were cow's milk (88%) and eggs (74%). After the period of dietary exclusion, total polyunsaturated FA showed no significant change, while saturated FA (SFA) declined, and monounsaturated FA (MUFA) increased. A decrease in fat intake was associated with an increase in arachidonic acid (ARA) and docosahexaenoic acid (DHA) content in BM (r = -0.37, r = -0.36; p < 0.05). However, a rise in ARA, eicosapentaenoic acid (EPA), and DHA intake was associated with an increase in linoleic acid and EPA in BM, respectively (r = 0.38, r = 0.55 and r = 0.41; p < 0.05). Infant weight-for-age z-score did not significantly change after the period of maternal dietary exclusion. Conclusion: Maternal exclusion diet resulted in lower SFA and higher MUFA composition in BM. Further study should explore the long-term outcomes of maternal dietary restriction on infant and child health.

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.

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.

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.

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.

The Association between Hepcidin and Iron Status in Children and Adolescents with Obesity.

INTRODUCTION: Iron deficiency (ID) is the most common nutritional deficiency found in pediatric practice. A higher prevalence of ID may be found in children with obesity. Obesity is a chronic low-grade inflammatory condition. It is postulated that inflammation increases hepcidin, a regulator of iron homeostasis. The aim of this study was to investigate the associations between iron status, hepcidin, and BMI-standard deviation score (BMI-SDS) in children with and without obesity. METHODS: A cross-sectional study of Thai children with obesity (5 to 15 years old) versus age- and sex-matched, nonobese controls was conducted. A total of 63 children with obesity and 27 controls were enrolled. Complete blood count, serum iron, ferritin, transferrin saturation, and total iron binding capacity were analyzed. Serum hepcidin-25 was assayed using a hepcidin ELISA Kit (Human Hepc25). RESULTS: There were 63 children with obesity, the median age (IQR) being 10 (9-13) years, and 27 controls. The median (IQR) BMI-SDS of the obese group was 2.3 (2.0-2.6) vs. -0.5 ((-1.3)-0.4) of the control group. ID was diagnosed in 27 children in the obese group (42.9%); 4 of the children with obesity and ID had anemia. Serum hepcidin-25 levels of the children with ID vs. without ID in the obese group were not significantly different (median (IQR) 25 (12.9-49.2) and 26.4 (12.6-43.6), respectively) but both of them were significantly higher than controls (19.7 (8.3-25.5) ng/ml, p = 0.04). BMI-SDS was positively correlated with hepcidin-25 (r = 0.28, p = 0.001). CONCLUSION: Prevalence of iron deficiency in Thai children with obesity and serum hepcidin-25 was higher than controls. Further study in a larger population, preferably with interventions such as weight loss program, is warranted to clarify this association.

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.

Anthropometric Markers and Iron Status of 6-12-Year-Old Thai Children: Associations and Predictors.

INTRODUCTION: Obesity may be associated with poor iron status. The objective of this study was to investigate the association between different indices of iron status and anthropometric measurements in Thai children. MATERIALS AND METHODS: Anthropometry (weight, height, waist circumference (WC), and body composition assessed by bioelectrical impedance analysis) and iron indices were measured in 336 Thai children aged 6-12 years. Iron deficiency (ID) was defined using two or more of the following: (1) %transferrin saturation (%Tsat) < 16%; (2) serum ferritin (SF) < 15 µg/mL; and (3) soluble transferrin receptor (sTfR) > 5 mg/L. Iron deficiency anaemia (IDA) was defined as haemoglobin < WHO age cutoff combined with ID. Overweight and obesity were defined as body mass index (BMI) standard deviation score (SDS) ≥ +1 SDS or +2 SDS, respectively (WHO growth reference). RESULTS: BMI SDS was significantly positively correlated with sTfR and SF (sTfR, r: 0.209, p < 0.001; SF, r: 0.214, p < 0.001) and negatively correlated with %Tsat (r: -0.132, p = 0.013). Correlations between WC SDS and %fat mass and each iron marker were similar. The percentage with low SF was significantly lower than that using other individual markers. ID prevalence was not significantly different between normal-weight and overweight/obesity groups although a significantly higher proportion of overweight/obese children had sTfR >5 mg/L. Puberty and menarche were significant predictors of ID (puberty adjusted OR: 2.20, 95% CI: 0.43, 11.25; menarche adjusted OR: 6.11, 95% CI: 1.21, 30.94). CONCLUSION: Greater adiposity was associated with poorer iron status. However, SF may not be a good indicator of iron status in Thai children, particularly in those who are overweight/obese, whereas sTfR merits further investigation.

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.