Society for Endocrinology (SfE) guidelines for the diagnosis and management of post bariatric hypoglycaemia.

Post bariatric hypoglycaemia (PBH) is typically a post-prandial hypoglycaemia occurring about 2-4 hours after eating in people who have undergone bariatric surgery. PBH develops relatively late after surgery and often after discharge from post-surgical follow-up by bariatric teams, leading to variability in diagnosis and management in non-specialist centres. AIM: to improve and standardise clinical practice in the diagnosis and management of PBH. OBJECTIVES: (1) to undertake an up-to-date review of the current literature; (2) to formulate practical and evidence-based guidance with regards on the diagnosis and treatment of PBH; (3) to recommend future avenues for research in this condition. METHOD: A scoping review was undertaken after an extensive literature search. A consensus on the guidance and confidence in the recommendations was reached by the steering group authors prior to review by key stakeholders. OUTCOME: We make pragmatic recommendations for the practical diagnosis and management of PBH including criteria for diagnosis and recognition, as well as recommendations for research areas that should be explored.

Tackling the dual burden of malnutrition in pregnancy - pregnancy after weight loss surgery.

The dual burden of malnutrition is characterised by the coexistence of undernutrition alongside overweight/obesity and diet-related noncommunicable diseases. It is a paradox which disproportionately affects women and is applicable to those who become pregnant after weight loss surgery. Obesity before and during pregnancy is associated with increased risk of adverse perinatal outcomes in both mother and child. Overall lifestyle interventions targeting weight loss in the preconception period have not proven effective, with people, and women in particular, increasingly seeking weight loss surgery. In women with severe obesity, surgery may normalise hormonal abnormalities and improve fertility. In those who become pregnant after surgery, evidence suggests a better overall obstetric outcome compared to those with severe obesity managed conservatively; however, there is heightened risk of maternal nutritional deficiencies and infants born small for gestational age. Specifically, pregnancy soon after surgery, in the catabolic phase when rapid weight loss is occurring, has the potential for poor outcomes. Lifelong micronutrient supplementation is required, and there is considerable risk of malnutrition if nutritional aftercare guidelines are not adhered to. It is therefore recommended that pregnancy is delayed until a stable weight is achieved and is supported by individualised advice from a multidisciplinary team. Further research is required to better understand how weight loss surgery affects the chances of having a healthy pregnancy and to ultimately improve nutritional management and patient care. In this review, we aim to summarise the evidence and guidance around nutrition during pregnancy after weight loss surgery.

What do readers want? Results of an online survey to involve readers in updating the seventh edition of the Manual of dietetic practice.

BACKGROUND: The Manual of dietetic practice ('Manual') is the core textbook for qualified and student dietitians. A survey was conducted to explore views on the scope, content and presentation of the Manual to inform the forthcoming edition. METHODS: The survey comprised of questions on demographics, structure, content, access (print/digital), missing topics, strengths and weaknesses. It was distributed to members of the British Dietetic Association (BDA) and other relevant groups in August 2022. Responses are presented as frequencies and free text as themes. RESULTS: Of 1179 responses, 91% were from professionals, of whom 72% were registered dietitians with a mean of 12.7 years (range: 1-44) in practice: 60% worked in the United Kingdom with 52% based in a clinical setting. The printed version was preferred: 59% professionals, 60% students, 94% professionals and 88% students were satisfied with the structure; however, 26% professionals and 22% students identified content that was lacking or outdated, including mental health and sustainability. The strengths were its comprehensive coverage and respected contributing authors. Weaknesses included the cost, size, lack of visual aids and currency. Professionals indicated the seventh edition should focus on more practical information required for clinical practice, whereas students wanted more emphasis on summarised information and visual formats. CONCLUSIONS: The survey proved a valuable method to engage with the readership to ensure the next edition reflected their requirements. Although nearly all respondents were satisfied with the scope and content, the results highlighted those topics lacking and/or outdated. Results also showed that the next edition should focus on practical information required for clinical practice, with more summarised and visual formats.

The Nutritional Online sUrvey for pRegnancy Induced Sickness & Hyperemesis (NOURISH) study: results from the first trimester.

BACKGROUND: Hyperemesis gravidarum (HG) is severe pregnancy sickness, often leading to dehydration, weight loss and electrolyte disturbances. Little is known about nutritional intake and its consequences in those affected. The aim of this study was to explore the first trimester nutritional intake and clinical characteristics in those with severe sickness. METHOD: Recruitment was via the social media accounts of national pregnancy charities. The eligibility criteria were as follows: between 6 and 11 weeks pregnant, age ≥18 years and residing in the UK. Participants completed a self-report online questionnaire including the Pregnancy Unique Quantification of Emesis 24 (PUQE24) score and a 3-day online diet diary. Groups were compared by PUQE24 categories. Nutritional intakes were compared to dietary reference values. RESULTS: One hundred sixty-six participants took part in the study: 36 categorised with mild, 109 with moderate and 21 with severe symptoms at a median gestation of 8.1 (interquartile range [IQR] 3) weeks. Those in the severe category had significantly higher weight loss (3.0 kg, IQR 3.5) than the mild category (0.0 kg, IQR 0.9). In those who completed the diet diary (n = 70), intakes of energy, carbohydrate, protein, fat, fibre, calcium, iron, zinc, thiamine, riboflavin, folate and vitamin C were all significantly lower in the severe category (p < 0.05). The severe group consumed only 39.5% and 41.6% of energy and protein needs, respectively, and were more likely to stop taking micronutrient supplements (p < 0.05). CONCLUSION: Nutritional and supplement intake in those with severe pregnancy sickness was poor; however, intake across all participants was suboptimal. Future research should investigate how to improve nutritional intake across all categories of pregnancy sickness.

Self-managed dietary changes and functional gut symptoms in endometriosis: A qualitative interview study.

Objective: Endometriosis is a chronic gynaecological condition, often causing gastrointestinal symptoms and misdiagnosed as irritable bowel syndrome (IBS). Endometriosis guidelines do not formally endorse dietary changes and little is known about how they are self-managed. The objective of this study is to understand nutritional practices and management of gut symptoms in people with endometriosis. Study design: Participants were recruited as part of a larger survey study via endometriosis support groups on social media. Eligibility criteria were: a self-reported physician-led diagnosis of endometriosis, over 18 years old and residing in the United Kingdom (UK). Semi-structured interviews were undertaken virtually via Zoom using a predefined interview guide. All interviews were transcribed and analysed using thematic analysis. Results: 10 people with endometriosis were interviewed. All had made individual dietary changes to manage their gut-related endometriosis symptoms. Dietary changes were made based on advice from social media support, books, websites or professionals other than dietitians. Changes included the restriction and exclusion of multiple essential food groups, including dairy, grains (primarily gluten), vegetables, fruits, and animal products. These changes impacted participants' weight, nutritional status and relationship with food. Four strong themes were identified: 1) impact of pain 2) severe and unpredictable gut symptoms 3) dietary changes and their impact 4) seeking support for dietetic intervention. A common thread underlying and linking these four main themes was the feeling of being dismissed, care being delayed and lack of support. Overall the long delay waiting for a diagnosis, surgery and, at times, the re-occurrence of symptoms post-surgery led to unsupported trial and error with modifiable lifestyle factors, including diet. Conclusion: Overall, participants demonstrated some patterns of restrictive eating behaviour and wanted more professional support to help manage their endometriosis-related gut symptoms. This highlights the need for dietitians to be involved in endometriosis care to help alleviate gut symptoms, whilst ensuring nutritional adequacy and offering weight management support where required.

Nutritional practices and dietetic provision in the endometriosis population, with a focus on functional gut symptoms.

BACKGROUND: Endometriosis is a common condition causing chronic pain, fatigue and gut symptoms. Research suggests that dietary changes may improve symptoms; however, evidence is lacking. The present study aimed to investigate the nutritional practices and needs of individuals with endometriosis (IWE) and the management of endometriosis by dietitians in the UK, focusing on gut symptoms. METHODS: Two online questionnaires were distributed via social media: a survey of dietitians working with IWE and functional gut symptoms and a survey of IWE. RESULTS: All respondents to the dietitian survey (n = 21) used the low fermentable oligosaccharides disaccharides monosaccharides and polyols (FODMAP) diet in IWE, with the majority 69.3% (n = 14), reporting positive adherence and patient benefit. Dietitians recommended more training (85.7%, n = 18) and resources (81%, n = 17) for IWE. Of those who completed the IWE questionnaire (n = 1385), 38.5% (n = 533) had coexisting irritable bowel syndrome. Only 24.1% (n = 330) had satisfactory relief of gut symptoms. The most common symptoms were tiredness, bloating and abdominal pain, experienced by 85.5% (n = 1163), 75.3% (n = 1025) and 67.3% (n = 917), respectively. Some 52.2% (n = 723) had tried dietary modifications to relieve their gut symptoms; 36.7% (n = 500) ate a restricted diet at present; 13.5% (n = 184) experienced recent unintentional weight loss and 29.8% (n = 407) a decreased appetite Some 13.2% (n = 183) had seen a dietitian regarding their gut symptoms. Of those who had not seen a dietitian, 57.7% (n = 693) would find it useful to. CONCLUSIONS: Gut symptoms and dietary restriction are very common in IWE; however, dietetic input is not. More research on the role of nutrition and dietetics in the management of endometriosis is recommended.

Iron supplementation during the first trimester of pregnancy after a national change of recommendation: a Danish cross-sectional study.

In 2013, the Danish Health Authorities recommended a change in prophylactic iron supplementation to 40-50 mg/d from gestational week 10. Hence, the aims of the present study were (1) to estimate the prevalence of women who follow the Danish recommendation on iron supplementation during the last 3 weeks of the first trimester of pregnancy and (2) to identify potential sociodemographic, reproductive and health-related pre-pregnancy predictors for iron supplementation during the first trimester. We conducted a cross-sectional study with data from the hospital-based Copenhagen Pregnancy Cohort. Characteristics were analysed by descriptive statistics and multivariable logistic regression analysis was performed to examine the associations between predictors and iron supplementation during the last 3 weeks of the first trimester. The study population consisted of 23 533 pregnant women attending antenatal care at Copenhagen University Hospital - Rigshospitalet from October 2013 to May 2019. The prevalence of iron supplementation according to recommendations was 49⋅1 %. The pre-pregnancy factors of ≥40 years of age, the educational level below a higher degree and a vegetarian or vegan diet were identified as predictors for iron supplementation during the first trimester of pregnancy. Approximately half of the women were supplemented with the recommended dose of iron during the first trimester of pregnancy. We identified pre-pregnancy predictors associated with iron supplementation. Interventions that target women of reproductive age are needed. An enhanced focus on iron supplementation during pregnancy should be incorporated in pre-pregnancy and interpregnancy counselling.

Mobile health as a primary mode of intervention for women at risk of or diagnosed with gestational diabetes mellitus: a scoping review.

OBJECTIVE: The objective of this review was to map the knowledge related to the use of mobile health (mHealth) as a primary mode of intervention for the prevention and management of gestational diabetes mellitus and its long-term implications among women at risk of or diagnosed with gestational diabetes mellitus. We also sought to understand if mHealth for women at risk of or diagnosed with gestational diabetes mellitus incorporated relevant behavior change theory and techniques. INTRODUCTION: Prevention and management of gestational diabetes mellitus and its associated adverse outcomes are important to maternal and infant health. Women with gestational diabetes mellitus report high burden of disease management and barriers to lifestyle change post-delivery, which mHealth interventions may help to overcome. Evidence suggests apps could help gestational diabetes mellitus prevention and management; however, less is known about broader applications of mHealth from preconception to interconception, and whether relevant behavior change techniques are incorporated. INCLUSION CRITERIA: Studies that focused on mHealth use as the primary mode of intervention for the prevention and management of gestational diabetes mellitus and its long-term implications were considered for inclusion. Telehealth or telemedicine were excluded as these have been reviewed elsewhere. METHODS: Six databases were searched: MEDLINE, CINAHL, Embase, Cochrane Library, Scopus, and TRIP. No limits were applied to database exploration periods to ensure retrieval of all relevant studies. Gray literature sources searched were OpenGrey, ISRCTN Registry, ClinicalTrials.gov, EU Clinical Trials Register, and ANZCTR. Two reviewers independently screened abstracts and assessed full texts against the inclusion criteria. Data were extracted using an adapted version of the JBI data extraction instrument. Data are presented in narrative form accompanied by tables and figures. RESULTS: This review identified 2166 sources, of which 96 full texts were screened. Thirty eligible reports were included, covering 25 different mHealth interventions. Over half (n = 14) of the interventions were for self-managing blood glucose during pregnancy. Common features included tracking blood glucose levels, real-time feedback, communication with professionals, and educational information. Few (n = 6) mHealth interventions were designed for postpartum use and none for interconception use. Five for postpartum use supported behavior change to reduce the risk oftype 2 diabetes and included additional features such as social support functions and integrated rewards. Early development and feasibility studies used mixed methods to assess usability and acceptability. Later stage evaluations of effectiveness typically used randomized controlled trial designs to measure clinical outcomes such as glycemic control and reduced body weight. Three mHealth interventions were developed using behavior change theory. Most mHealth interventions incorporated two behavior change techniques shown to be optimal when combined, and those delivering behavior change interventions included a wider range. Nevertheless, only half of the 26 techniques listed in a published behavior change taxonomy were tried. CONCLUSIONS: mHealth for gestational diabetes mellitus focuses on apps to improve clinical outcomes. This focus could be broadened by incorporating existing resources that women value, such as social media, to address needs, such as peer support. Although nearly all mHealth interventions incorporated behavior change techniques, findings suggest future development should consider selecting techniques that target women's needs and barriers to engagement. Lack of mHealth interventions for prevention of gestational diabetes mellitus recurrence and type 2 diabetes mellitus suggests further development and evaluation are required.

Nutritional consequences and management of hyperemesis gravidarum: a narrative review.

Hyperemesis gravidarum (HG) is a condition at the extreme end of the pregnancy sickness spectrum, estimated to affect 1-2 % of pregnant women. This narrative review provides an overview of the current literature concerning the nutritional implications and management of HG. HG can persist throughout pregnancy, causing malnutrition, dehydration, electrolyte imbalance and unintended weight loss, requiring hospital admission in most cases. In addition to its negative effect on maternal, physical and psychological wellbeing, HG can negatively impact fetal growth and may have adverse consequences on the health of the offspring. HG care and research have been hampered in the past due to stigma, inconsistent diagnostic criteria, mismanagement and lack of investment. Little is known about the nutritional intake of women with HG and whether poor intake at critical stages of pregnancy is associated with perinatal outcomes. Effective treatment requires a combination of medical interventions, lifestyle changes, dietary changes, supportive care and patient education. There is, however, limited evidence-based research on the effectiveness of dietary approaches. Enteral tube feeding and parenteral nutrition are generally reserved for the most intractable cases, where other treatment modalities have failed. Wernicke encephalopathy is a rare but very serious and avoidable consequence of unmanaged HG. A recent priority-setting exercise involving patients, clinicians and researchers highlighted the importance of nutrition research to all. Future research should focus on these priorities to better understand the nutritional implications of HG. Ultimately improved recognition and management of malnutrition in HG is required to prevent complications and optimise nutritional care.

Preterm births in South-West England before and during the COVID-19 pandemic: an audit of retrospective data.

The COVID-19 lockdown had a series of intended and unintended consequences, including reduced infections and changes in activities and behaviours. Some of these changes may have been beneficial to perinatal outcomes; however, other factors such as reduced access to face-to-face healthcare may have contributed negatively to antenatal care. The aim of this audit was to evaluate neonatal admissions in the South-West of England during the COVID-19 pandemic in 2020 and the previous two years 2018-2019. Anonymised birth and neonatal admission rates from January to December 2020 was obtained and compared to data from 2018 to 2019. The results demonstrate a decreasing in neonatal unit admissions between 2018 and 2020, 9.48% of live births in 2018 (95% CI 9.17, 9.80) to 8.89% (95% CI 8.65, 9.13) in 2020 (p = 0.002).Conclusion: There were no significant differences across gestational groups. It is unclear without nationwide data whether our observed trends, decreased neonatal admissions over the past 3 years, are generalisable and related to the COVID-19 pandemic. Future research exploring the impact of lockdowns on behaviour change during pregnancy and support services is warranted to understand the implications of pandemics on pregnancy and preterm birth. What is Known: • The COVID-19 lockdown had a series of intended and unintended consequences; some of which may have been beneficial to perinatal outcomes. • Research suggests that preterm births have not significantly changed overall, but they have decreased in high-income countries. What is New: • In our audit, analysing retrospective data of regional birth and neonatal admission from the South-West of England, we observed a decrease in live birth rates between 2018 and 2020. • A reduction in neonatal unit admissions was observed from 2018 to 2020 with no significant differences across gestational groups. The reduction from 2019 to 2020 was smaller than that from 2018 to 2019 implying that the COVID-19 pandemic in 2020 was not necessarily implicated.

Advanced glycation end product intake during pregnancy and offspring allergy outcomes: A Prospective cohort study.

BACKGROUND: Associations have been shown between concurrent assessment of dietary intake of advanced glycation end products (AGEs) and childhood allergic outcomes. We examined the association between maternal AGEs intake and development of offspring asthma, wheeze, atopic dermatitis, allergic rhinitis and food allergies, and sought to determine whether the intake of AGEs was associated with cord sera cytokines/chemokines. METHODS: Pregnant women ≥16 years were recruited in the Healthy Start study, a prospective pre-birth cohort from Colorado (N = 1410). The analysis included 962 dyads with adequate diet (≥2 recalls) and allergy outcome details. AGEs intake was estimated for each mother by matching intakes reported using 24-h dietary recalls during pregnancy to a reference database of commonly consumed foods' AGEs values. Child diagnoses of asthma and allergies up to 8 years were obtained from electronic medical records. Cord sera cytokines and chemokines were analysed in a subset (N = 462) of children. RESULTS: The median [IQR] AGEs intake for the overall sample was 11,919 kU/day [8293, 16,573]. Unadjusted analysis showed a positive association between maternal AGEs intake in pregnancy and rhinitis up to 8 years of age (HR = 1.03; 95% CI: 1.01, 1.06), but the association was attenuated and no longer significant in adjusted models (HR = 1.01; 95% CI: 0.98, 1.04). Both adjusted and unadjusted models showed no associations between AGEs intake in pregnancy and any of the other outcomes (p > .05). There were no significant associations between any cytokine or chemokine measured and AGEs intake or any of the outcomes studied (p > .05). CONCLUSION: The study showed that maternal AGEs intake was not associated with offspring asthma and allergy outcomes. AGEs exposure during pregnancy may not have the same impact on child development as postnatal exposure.

Bone turnover in pregnancy, measured by urinary CTX, is influenced by vitamin D supplementation and is associated with maternal bone health: findings from the Maternal Vitamin D Osteoporosis Study (MAVIDOS) trial.

BACKGROUND: The pattern of change in maternal bone turnover throughout pregnancy is poorly characterized. OBJECTIVES: We investigated changes across pregnancy in a marker of maternal bone resorption, urinary C-terminal telopeptide of type I collagen (CTX), the influence of gestational vitamin D supplementation, and associations between CTX and maternal postnatal bone indices. METHODS: MAVIDOS (the Maternal Vitamin D Osteoporosis Study) is a randomized, double-blind, placebo-controlled trial of 1000 IU cholecalciferol/d compared with placebo from 14 weeks of gestation to birth. Maternal second-void urinary α- and ß-CTX were measured (ELISA) at 14 and 34 weeks of gestation; DXA was performed within 2 wk postpartum. The Mann-Whitney Rank Sum test, Spearman's rank correlation, and linear regression were used to compare median CTX values within and between groups from early to late pregnancy, and associations with maternal bone outcomes. RESULTS: In total, 372 women had CTX and 25-hydroxyvitamin D [25(OH)D] measured in early and late pregnancy. CTX at 14 and 34 weeks of gestation were correlated in both placebo (r = 0.31) and cholecalciferol (r = 0.45) groups (P < 0.0001). Median CTX increased from 14 to 34 weeks of gestation in both groups (n = 372 total) [placebo (n = 188): from 223.6 to 449.7 µg/mmol creatinine; cholecalciferol (n = 184): from 222.3 to 419.3 µg/mmol creatinine; P = 0.03 for placebo compared with cholecalciferol difference in CTX at 34 weeks of gestation]. The conditional mean ± SD increase in CTX [z-score (SD)] from early to late pregnancy was greater in the placebo group (n = 188) than in the cholecalciferol group (n = 184) (placebo: 0.16 ± 0.92; cholecalciferol: -0.16 ± 1.06; P-difference < 0.01). Higher CTX at 34 weeks of gestation was associated, similarly in both groups, with lower maternal total hip and lumbar spine bone mineral content and bone mineral density (BMD) (e.g., lumbar spine BMD: ß = -0.02 g · cm-2 · SD-1 increase in CTX; 95% CI: -0.027, -0.002 g · cm-2 · SD-1; P = 0.02, n = 283). CONCLUSIONS: Maternal urinary CTX, a bone resorption marker, rises through pregnancy, although to a lesser degree with gestational cholecalciferol supplementation, and is inversely associated with maternal bone mass postpartum.This trial was registered at www.isrctn.com as ISRCTN 82927713 and eudract.ema.europa.eu as EudraCT 2007-001716-23.

Phase Angle and Bio-Impedance Values during the First Year after Delivery in Women with Previous Excessive Gestational Weight Gain: Innovative Data from the Belgian INTER-ACT Study.

Phase angle (PhA) is a body composition parameter that measures changes in the amount and quality of soft tissue. Few studies have explored PhA in pregnancy or postpartum. The aim of this study was to explore the PhA during the first year postpartum in a Belgian cohort using data from the control group of the INTER-ACT study, an intervention trial targeting those with excess gestational weight gain. A secondary aim was to examine associations between PhA and potential explanatory variables. Women aged ≥18 with excessive weight gain in a singleton pregnancy and without a chronic disease were eligible. Data collection included anthropometry as well as demographic and lifestyle questionnaires at 6 weeks, 6 months and 12 months postpartum. Body composition, including PhA, was measured with the Tanita MC780SMA device. Data was analysed using correlation and mixed model analyses. A total of 509 participants (median age 31.2) were included. The median PhA at 6 weeks postpartum was 5.8°. Higher PhA values were seen in multiparous women (p = 0.02) but there was no association with any other lifestyle or demographic factors. PhA values were positively associated with muscle mass and BMI (r = 0.13, p = 0.004 and r = 0.18, p < 0.001) at 6 weeks postpartum. PhA increased slightly in the 12 months postpartum, which was related to a decrease in fat percentage (p = 0.004). Further research in the pregnant/postpartum population is needed to elucidate any links with perinatal or future health outcomes.

The Contribution of Registered Dietitians in the Management of Hyperemesis Gravidarum in the United Kingdom.

Hyperemesis Gravidarum (HG) is a condition at the extreme end of the pregnancy sickness spectrum, which can cause poor oral intake, malnutrition, dehydration and weight loss. The aim of this study is to explore the role of Registered Dietitians (RD) in the management of HG in the United Kingdom (UK). A survey was designed and distributed electronically to members of the British Dietetic Association. There were 45 respondents, 76% (n = 34) worked in secondary care hospitals, 11% (n = 5) were in maternal health specialist roles. The most commonly used referral criteria was the Malnutrition Universal Screening Tool (40%, n = 18), followed by second admission (36%, n = 16). However 36% (n = 16) reported no specific referral criteria. About 87% (n = 37) of respondents did not have specific clinical guidelines to follow. Oral nutrition supplements were used by 73% (n = 33) either 'sometimes' or 'most of the time'. Enteral and parenteral nutrition were less commonly used. There was an inconsistent use of referral criteria to dietetic services and a lack of specific clinical guidelines and patient resources. Further training for all clinicians and earlier recognition of malnutrition, alongside investment in the role of dietitians were recommended to improve the nutritional care of those with HG.

The use of Breast Milk Fortifier in Preterm Infants by paediatric dietitians in the UK.

BACKGROUND: Breast milk is the feed of choice for premature infants, although its nutritional composition is not always sufficient to meet their raised nutritional requirements. The addition of a multi-nutrient breast milk fortifier (BMF) to breastmilk is recommended; however, international guidelines on the use of BMF are inconsistent. The present study aimed to explore the use of BMF in preterm infants by paediatric dietitians in the UK. METHODS: A questionnaire was designed and sent to members of the British Dietetic Association neonatal specialist group (n = 100) using a secure online platform. Descriptive statistics were calculated. RESULTS: Forty dietitians completed the survey, all of whom used BMF. Local hospital BMF guidelines were available to 77.5% (n = 31). The most commonly used criteria for commencing BMF were: tolerating a feed volume of 150 mL kg-1  day-1 (72.5%, n = 29), a gestational age <34 weeks (67.5%, n = 27) and a birth weight <1500 g (60%, n = 24). The primary contraindication for the use of BMF was necrotising enterocolitis (NEC). The majority of respondents used standard fortification, with individualised fortification available to only 12.5% (n = 5). The most common indicators for discontinuing BMF were on discharge home (67.5%, n = 27), satisfactory growth (65%, n = 26) or feeding directly from the breast (62.5%, n = 25). CONCLUSIONS: Although BMF is used more proactively in UK neonatal units than previously, variation in practice remains. Individualised fortification is very uncommon and caution remains regarding risk of NEC. The development of national guidelines on the use of BMF would help to standardise nutritional care in neonatal units.

mHealth as a primary mode of intervention for women at risk of, or diagnosed with, gestational diabetes: a scoping review protocol.

OBJECTIVE: To synthesize current knowledge on the use of mHealth as a primary mode of intervention for the prevention and management of gestational diabetes mellitus and its long-term implications among women at risk of, or diagnosed with, gestational diabetes mellitus. INTRODUCTION: Prevention and management of gestational diabetes mellitus and its associated adverse outcomes are of paramount importance to both maternal and infant health. However, women with experience of gestational diabetes mellitus report several barriers to effective disease management and lifestyle change. Supporting women through use of mHealth technology may help overcome these barriers. Recent evidence suggests mobile apps may be useful for the prevention and management of gestational diabetes mellitus, however, less is known about the broader application of mHealth from preconception to interconception. INCLUSION CRITERIA: Studies considered for inclusion are those focused on the use of mHealth as the primary mode of intervention for the prevention and management of gestational diabetes mellitus and its long-term implications among women at risk of, or diagnosed with, gestational diabetes mellitus. Studies will be limited to those published in English, with no date restrictions. METHODS: The following databases will be searched: MEDLINE (Ovid), CINAHL (EBSCO), EMBASE (Ovid), Cochrane Database (Wiley), Scopus, and TRIP. Unpublished studies and gray literature will be searched using Open Grey, ISRCTN Registry, ClinicalTrials.gov, EU Clinical Trials register, and ANZCTR. Two reviewers will independently screen abstracts. Reviewers will assess full texts of selected citations against the inclusion criteria. Any disagreements will be discussed with a third reviewer. Data will be extracted and presented in diagrammatic or tabular form with an accompanying narrative in line with review objectives.

What is known about the nutritional intake of women with Hyperemesis Gravidarum?: A scoping review.

Hyperemesis gravidarum (HG) is characterised by extreme nausea and vomiting of pregnancy, which can lead to dehydration, weight loss and electrolyte disturbances. Historically research has been challenging due to a lack of diagnostic criteria and objective outcome measures. Most studies in this population group have focused on medical management of symptoms, with little known about the effect of HG on nutritional intake and how this relates to perinatal outcomes. The aim of this study was to synthesise current knowledge of the dietary intake of women with HG. A systematic search of search engines was conducted in April 2020 using the following databases: MEDLINE, Embase, CINAHL, Cochrane database, Scopus, NHS Evidence, BNI, Emcare, ClinicalTrials.gov, PROSPERO, Ethos and Open Grey. Titles and abstracts were screened independently by two reviewers against predefined inclusion and exclusion criteria. Studies were included where the authors described severe pregnancy nausea and vomiting as HG, regardless of how HG was defined. After removal of duplicates, 4402 titles were identified, of which 3992 were initially excluded based on abstract and title. Following full text review, four of 10 articles were included. Three of the studies were hospital-based case control studies, one was an observational women's cohort study. Assessment of dietary intake was heterogeneous, with both retrospective and prospective self-report methods used, over different timeframes. In three of the studies, dietary intake was reported at one time point only. In total, across all four studies, data from only 314 women were included. Overall, despite data collected from four different countries, over 30 years, with various methods, women with HG had a significantly poorer dietary intake compared to non-affected pregnant women, consuming less than 50 % of recommended intakes for most nutrients. Nutritional intake worsened with increasing severity of symptoms. As this was a scoping review, study quality was not assessed. Overall, this review has identified a paucity of data about the dietary intake of women with HG; the limited available data indicates that women with HG are at risk of malnutrition. Future research quantifying nutritional intake in women with HG at several time points during pregnancy would provide valuable reference data, enabling nutritional status and outcomes to be monitored and interventions to be evaluated.

Dietary factors during pregnancy and atopic outcomes in childhood: A systematic review from the European Academy of Allergy and Clinical Immunology.

RATIONALE: Allergic diseases are an increasing public health concern, and early life environment is critical to immune development. Maternal diet during pregnancy has been linked to offspring allergy risk. In turn, maternal diet is a potentially modifiable factor, which could be targeted as an allergy prevention strategy. In this systematic review, we focused on non-allergen-specific modifying factors of the maternal diet in pregnancy on allergy outcomes in their offspring. METHODS: We undertook a systematic review of studies investigating the association between maternal diet during pregnancy and allergic outcomes (asthma/wheeze, hay fever/allergic rhinitis/seasonal allergies, eczema/atopic dermatitis (AD), food allergies, and allergic sensitization) in offspring. Studies evaluating the effect of food allergen intake were excluded. We searched three bibliographic databases (MEDLINE, EMBASE, and Web of Science) through February 26, 2019. Evidence was critically appraised using modified versions of the Cochrane Collaboration Risk of Bias tool for intervention trials and the National Institute for Clinical Excellence methodological checklist for cohort and case-control studies and meta-analysis performed from RCTs. RESULTS: We identified 95 papers: 17 RCTs and 78 observational (case-control, cross-sectional, and cohort) studies. Observational studies varied in design and dietary intakes and often had contradictory findings. Based on our meta-analysis, RCTs showed that vitamin D supplementation (OR: 0.72; 95% CI: 0.56-0.92) is associated with a reduced risk of wheeze/asthma. A positive trend for omega-3 fatty acids was observed for asthma/wheeze, but this did not reach statistical significance (OR: 0.70; 95% CI: 0.45-1.08). Omega-3 supplementation was also associated with a non-significant decreased risk of allergic rhinitis (OR: 0.76; 95% CI: 0.56-1.04). Neither vitamin D nor omega-3 fatty acids were associated with an altered risk of AD or food allergy. CONCLUSIONS: Prenatal supplementation with vitamin D may have beneficial effects for prevention of asthma. Additional nutritional factors seem to be required for modulating the risk of skin and gastrointestinal outcomes. We found no consistent evidence regarding other dietary factors, perhaps due to differences in study design and host features that were not considered. While confirmatory studies are required, there is also a need for performing RCTs beyond single nutrients/foods.

Different Measures of Diet Diversity During Infancy and the Association with Childhood Food Allergy in a UK Birth Cohort Study.

BACKGROUND: Diet diversity (DD) during infancy may prevent food allergies (FA), possibly by exposing the gastrointestinal microbiota to diverse foods and nutrients. OBJECTIVE: To investigate the association between 4 different measures of DD during infancy and development of FA over the first decade of life. METHODS: A birth cohort born between 2001 and 2002 were followed prospectively, providing information on sociodemographic, environmental, and dietary exposures. Information on age of introduction of a range of foods and food allergens was collected during infancy. Children were assessed for FA at 1, 2, 3, and 10 years. DD was defined using 4 measures in the first year of life: the World Health Organization definition of minimum DD at 6 months, as food diversity (FD) and fruit and vegetable diversity (FVD) at 3, 6, and 9 months, and as food allergen diversity (FAD) at 3, 6, 9, and 12 months. RESULTS: A total of 969 pregnant women were recruited at 12-week gestation. A total of 900, 858, 891, and 827 offspring were assessed at 1, 2, 3, and 10 years. Univariate analysis showed that World Health Organization DD (P = .0047), FD (P = .0009), FAD (P = .0048), and FVD (P = .0174) at 6 months and FD (P = .0392), FAD (P = .0233), and FVD (.0163) at 9 months significantly reduced the odds of FA over the first decade of life. DD measures at 3 months were not associated with FA, but only 33% of the cohort had solid foods introduced by this age. CONCLUSION: Increased infant DD, as measured by 4 different methods, decreased the likelihood of developing FA.