Practices of Introduction of Complementary Feeding and Iron Deficiency Prevention in the Middle East and North Africa.

BACKGROUND: Iron deficiency (ID) with or without anemia is associated with impaired mental and psychomotor development. Given the paucity of information on physicians' knowledge and practices on iron (Fe) supplementation and impact of ID in the Middle East and North Africa, it was felt important to conduct a survey. METHOD: A group of expert physicians developed a questionnaire that was randomly distributed among Middle East and North Africa doctors to assess their knowledge and practices on introduction of complementary feeding, impact of ID, its prevention, and their impression on prevalence of ID. Descriptive statistics were used. RESULTS: We received 2444 completed questionnaires. Thirty-nine percent of physicians do not follow the European Society for Paediatric Gastroenterology, Hepatology and Nutrition guidelines regarding age of introduction of complementary feedings. Approximately 62% estimate the prevalence of ID anemia to be 40% to 70%; however, only 17% always monitor hemoglobin between 9 and 12 months of age, 43% do so "almost" always, whereas 36% do so "rarely" or (4%) "never." For the prevention of ID in infants older than 6 months of age, almost all recommend introducing Fe supplements. Ninety-seven percent agree that untreated ID during infancy may have long-term negative effects on cognitive function, whereas 53.26% consider that Fe-enriched infant cereals result in staining of the baby teeth, constipation, and dark stools. CONCLUSIONS: Although there is awareness of the impact of ID, there are some misconceptions regarding age of introduction of complementary feedings, surveillance of Fe status, and side effects of Fe-enriched infant cereals. There is a need for educational initiatives focusing on prevention of Fe deficiency.

Chapter 4. The Relationship Between the European and North American Societies for Pediatric Gastroenterology, Hepatology and Nutrition.

This chapter is based on the memories of those who shaped the relationship between the European and the North American Societies for Pediatric Gastroenterology, Hepatology and Nutrition. The first joint meeting of the 2 Societies took place in Paris in 1978, followed by 1 in New York in 1985, 1 in Amsterdam in 1990, 1 in Houston in 1994, and the last one in Toulouse in 1998. The formation of the Federation of the International Societies for Pediatric Gastroenterology, Hepatology and Nutrition (FISPGHAN) preceded the First World Congress of all Societies, which took place in Boston in 2000. The success of this meeting was followed by world congresses in Paris in 2004, Iguassu in 2008, Taiwan in 2012, and Montreal in 2016. NASPGHAN and ESPGHAN jointly took on the direction of the Journal of Pediatric Gastroenterology and Nutrition in 1991. Communication between the 2 Societies is extremely active, with members participating in many joint projects.

Intestinal permeability to lactulose and mannitol in growing rats with iron-deficiency anemia.

Iron deficiency can have nonhematological manifestations, some of which may affect the gastrointestinal tract. The aim of this study was to determine if iron-deficiency anemia in growing rats affected small-bowel permeability as assessed by the urinary ratio of lactulose and mannitol. Thirty-seven male Harlan Sprague-Dawley rats (21 d of age) were randomly divided into two groups and fed either an iron-deficient (n=19) or an iron-sufficient diet (n=18) that contained either 13.5 or 43.8 mg of iron/kg diet, respectively. Animals were evaluated between 25 and 38 d of dietary treatment. Intestinal permeability was assessed by measuring the lactulose/mannitol urinary ratio following administration of a solution that contained the two sugars. At the end of the study, the mean body weight of rats fed the low-iron diet was approx 95% that of the controls. The mean hemoglobin (g/dL) was significantly lower in the low-iron diet group (11.2+/-1.4) than in the control group (16.9+/-0.8) (p=0.001). The liver iron concentration (microg/g) of the anemic group (41.4+/-4.7) was also statistically (p=0.001) lower than in the control group (116.6+/-18.2). The lactulose/mannitol ratio was lower in the anemic rats (2.0+/-0.7) than in the control group (2.6+/-0.7) (p=0.008), a finding that is not suggestive of intestinal mucosal atrophy, previously described in anemic children.

Effect of orange and apple juices on iron absorption in children.

OBJECTIVE: To measure iron absorption in children from meals containing apple juice or orange juice so as to determine if iron absorption will be greater with orange juice because of its higher ascorbic acid content than apple juice, a noncitrus fruit juice that US children reportedly prefer. DESIGN: On 2 successive days, children consumed identical meals that included apple juice on one day and orange juice on the other, in random order. The meals were labeled with iron-57 on one day and iron-58 on the other. Iron absorption was measured from red blood cell incorporation of the iron stable isotopes 14 days later. SETTING: Nutrition research institute in a major metropolitan medical center. PATIENTS: A total of 25 healthy children, 3 to 6 years of age, were recruited, of whom 21 (11 male and 10 female) completed the study. Intervention Identical meals served with orange juice and apple juice were given on consecutive days, in a balanced randomized design. MAIN OUTCOME MEASURES: Iron absorption measured by established stable isotope methods. RESULTS: Median iron absorption from the meal ingested with apple juice was 7.17% (mean +/- SD, 9.48% +/- 9.68%). Median iron absorption from the meal ingested with orange juice was 7.78% (9.80% +/- 6.66%; P =.44). Iron absorption from the meal that included apple juice was significantly correlated with serum ferritin concentration (P =.02); iron absorption from the meal that included orange juice tended to correlate with serum transferrin receptor concentration (P =.051). CONCLUSIONS: As children absorb iron well from a meal that includes either orange or apple juice, a preference for apple juice does not pose a concern with regard to the prospect of iron-deficiency anemia, which remains a significant health problem in the United States.

Carbohydrate digestion in humans from a beta-glucan-enriched barley is reduced.

Obese and diabetic patients may benefit from foodstuffs that are poorly absorbed and/or digested at a slower rate. Prowashonupana (PW) is a cultivar of barley, whose grains are enriched in beta-glucans, and thus may be less digestible than standard barley (barley cultivar (BZ) 594.35.e). To test this, both kinds of barley were grown in a chamber into which (13)CO(2) was injected. On two occasions, 10 healthy hydrogen (H(2))-producing adults consumed in random order one 35-g portion of each of the cooked, dehulled (13)C-enriched grains. CO(2) production was measured in a whole-body direct calorimeter, and H(2) and (13)CO(2) were measured in breath at baseline and intermittently for 450 min. The percentage of the (13)C dose recovered in breath was calculated. Results were compared by repeated measures analysis of variance (ANOVA). The percentage of the (13)C dose oxidized was greater after BZ than after PW consumption (P < 0.05). The area under the curve for H(2) was greater after PW (mean +/- SD, 8658 +/- 6582) than after BZ (5178 +/- 4759) intake (P < 0.05), whereas there was no difference in CO(2) production. We conclude that absorption of PW is significantly lower than that of BZ, making the modified barley appropriate for obese and diabetic patients.

Feeding Problems in Infants and Children.

This article focuses on factors related to decreased food intake of infants and children, but does not address anorexia or bulimia nervosa. The nature of feeding problems may be behavioral, organic, or a mixture of both. Behavioral problems that affect intake have their roots in 1) parental or cultural expectations for food intake and body habit, 2) parental anxiety about weight gain in a vulnerable child or insecurity about parental skills, 3) power struggles between parent and child that manifest in eating habits, 4) conditions that may have enhanced the gag reflex, such as prolonged orotracheal intubation or a nasogastric tube, 5) failure to establish links between hunger, food intake, and satiety in infants who had not been fed orally for a relatively prolonged period of time at a critical age, and 6) anxiety or depression. Organic causes that lead to decreased food intake include swallowing problems (neurologic or conditioned hypersensitive gag, structural anomalies of the oropharynx, dyscoordinated swallow, painful swallow, and obstructed swallow ), respiratory distress, excessive fatigability (heart failure, respiratory failure), and lack of appetite (many chronic systemic illnesses). At particular risk for feeding problems are infants of premature birth, children with craniofacial anomalies, those with certain genetic syndromes, and those with neurologic involvement. An evaluation by specialists is recommended for children with obvious behavioral problems but for whom the usual recommendations have failed and for those in whom symptoms cannot be explained solely by behavioral issues or in whom organic causes are suspected. The evaluation preferably should be performed by a team specialized in pediatric feeding disorders or otherwise by an occupational therapist or speech pathologist with expertise in the area of feeding.