Role of Pediatricians in Promoting and Supporting Breastfeeding: A Position Paper of the International Pediatric Association Strategic Advisory Group on Infant, Child, and Adolescent Nutrition.

BACKGROUND: Promoting and supporting breastfeeding is an important public health intervention with multiple benefits for both infants and mothers. Even modest increases in the prevalence and duration of breastfeeding could significantly reduce healthcare costs and improve maternal and child health outcomes. However, widespread adoption of breastfeeding recommendations remains poor in most settings, which contributes to widening health and social inequalities. Pediatricians have a duty to advocate for improving child health, including promoting and supporting breastfeeding. SUMMARY: This paper, from the International Pediatric Association Special Advisory Group on Nutrition, considers common barriers to breastfeeding and addresses how pediatricians can better promote and support breastfeeding, both at an individual level and by influencing practice and policy. All pediatricians need to understand the basics of breastfeeding, including lactation physiology, recognize common breastfeeding problems, and advise mothers or refer them for appropriate support; training curricula for general pediatricians and all pediatric subspecialties should reflect this. Even in the situation where their day-to-day work does not involve direct contact with mothers and infants, pediatricians can have an important influence on policy and practice. They should support colleagues who work directly with mothers and infants, ensuring that systems and environments are conducive to breastfeeding and, where appropriate, milk expression. Pediatricians and pediatric organizations should also promote policies aimed at promoting and supporting breastfeeding at local, regional, national, and international levels. KEY MESSAGES: Pediatricians have a duty to promote and support breastfeeding, regardless of their day-to-day role and responsibilities. Pediatric training curricula should ensure that all trainees acquire a good understanding of breastfeeding so they are able to effectively support mothers in their personal practice but also influence breastfeeding practice and policy at a local, regional, national, and international level.

International Latin American Survey on Pediatric Intestinal Failure Team.

There is little data on the experience of managing pediatric Intestinal Failure (IF) in Latin America. This study aimed to identify and describe the current organization and practices of the IF teams in Latin America and the Caribbean. An online survey was sent to inquire about the existence of IF teams that managed children on home parenteral nutrition (HPN). Our questionnaire was based on a previously published European study with a similar goal. Twenty-four centers with pediatric IF teams in eight countries completed the survey, representing a total number of 316 children on HPN. The median number of children on parenteral nutrition (PN) at home per team was 5.5 (range 1-50). Teams consisted of the following members: pediatric gastroenterologist and a pediatric surgeon in all teams, dietician (95.8%), nurse (91.7%), social worker (79.2%), pharmacist (70.8%), oral therapist (62.5%), psychologist (58.3%), and physiotherapist (45.8%). The majority of the centers followed international standards of care on vascular access, parenteral and enteral nutrition, and IF medical and surgical management, but a significant percentage reported inability to monitor micronutrients, like vitamins A (37.5%), E (41.7%), B1 (66.7%), B2 (62.5%), B6 (62.5%), active B12 (58.3%); and trace elements-including zinc (29.2%), aluminum (75%), copper (37.5%), chromium (58.3%), selenium (58.3%), and manganese (58.3%). Conclusion: There is wide variation in how IF teams are structured in Latin America-while many countries have well-established Intestinal rehabilitation programs, a few do not follow international standards. Many countries did not report having an IF team managing pediatric patients on HPN.

Amino acid formula as a new strategy for diagnosing cow's milk allergy in infants: is it cost-effective?

AIMS: To estimate the cost-effectiveness of a new strategy that uses an amino acid formula in the elimination diet of infants with suspected cow's milk allergy (CMA). MATERIALS AND METHODS: This pharmacoeconomic study was developed from the perspective of the Brazilian Public Healthcare System. The new strategy proposes using an amino acid formula in the diagnostic elimination diet of infants (≤24 months) with suspected CMA. The rationale is that infants who do not respond to the amino acid formula do not suffer from CMA. Patients with a positive oral challenge test receive a therapeutic elimination diet based on Brazilian Food Allergy Guidelines. This approach was compared to the current recommendations of the Brazilian Food Allergy Guidelines. A decision model was constructed using TreeAge Pro 2012 software. Model inputs were based on a literature review and the opinions of a panel of experts. A univariate sensitivity analysis of incremental cost-effectiveness ratios was performed. RESULTS: The mean cost per patient of the new amino acid formula strategy was R$3,341.57, while the cost of the current Brazilian guidelines strategy was R$3,641.08. The mean number of symptom-free days per patient, which was used as an indicator of effectiveness, was 900.6 and 875.7 days, respectively. The new strategy is, therefore, dominant. In the sensitivity analysis, the dominance was maintained with parameter variation. LIMITATIONS: In the absence of information in the literature, some premises were defined by a panel of specialists. CONCLUSIONS: The new strategy, which uses an amino acid formula in the elimination diagnostic diet followed by an oral food challenge, is a dominant pharmacoeconomic approach that has a lower cost and results in an increased number of symptom-free days.

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

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

[Guía latinoamericana para el diagnóstico y tratamiento de alergia a las proteínas de la leche de vaca (GL-APLV)].

Cow's milk allergy (CMA) is an immune-based disease that has become an increasing problem. The diagnosis and management of CMA varies from one clinical setting to another and represents a challenge in pediatric practice. In addition, because nonallergic food reactions can be confused with CMA symptoms, there is an overdiagnosis of the disease. In response to these situations, pediatric specialties from recognized institutions throughout Latin America decided to develop a clinical guideline for diagnosis and management of cow's milk allergy. These guidelines include definitions, epidemiology, pathophysiology overview, clinical and evidencebased recommendations for the diagnosis and treatment of CMA. They also include prevention and prognosis sections and identify gaps in the current knowledge to be addressed through future research.

Alergia ao leite de vaca: achados do ultrassom com Doppler colorido em neonatos com hematoquezia / Cow's milk allergy: color Doppler ultrasound findings in infants with hematochezia

OBJETIVO: o ultrassom (US) tem sido uma importante ferramenta de diagnóstico para identificar várias causas de hemorragia gastrointestinal. Neonatos com alergia ao leite de vaca (ALV) podem apresentar hematoquezia, e a confirmação do diagnóstico pode ser difícil. O objetivo deste estudo é descrever achados com ultrassom em escala de cinza e com Doppler colorido em pacientes com ALV. MÉTODOS: estudamos, retrospectivamente, 13 neonatos com ALV. Todos eles apresentaram hematoquezia severa e dor abdominal e foram submetidos a um estudo com US, com o diagnóstico de colite alérgica. O diagnóstico teve como base os achados clínicos, a recuperação após a dieta de exclusão do neonato ou da mãe, no caso de amamentação exclusiva, e o teste de provocação oral positivo. RESULTADOS: a idade média variou de um a seis meses (média = 3,53). Sete dos 13 neonatos (53,8%) passaram novamente por ultrassonografia em escala de cinza e com Doppler colorido após a dieta de exclusão. Dentre eles, 12 dos 13 (92,3%) mostraram anormalidades no US e no ultrassom com Doppler colorido (USDC) no início. Os achados positivos que sugeriram colite foram paredes intestinais espessas e aumento na vascularização, principalmente no cólon descendente e sigmoide. Os resultados da colonoscopia e histopatológicos foram compatíveis com colite alérgica. Após uma mudança na dieta, os 13 neonatos se recuperaram e seus testes de provocação oral foram positivos. CONCLUSÃO: o US com Doppler pode ser muito útil para diagnosticar a colite secundária, como a ALV, e para excluir várias outras doenças abdominais que podem imitar essa doença.

OBJECTIVE: ultrasound (US) has been an important diagnostic tool to identify several causes of gastrointestinal bleeding. Infants with cow's milk allergy (CMA) may present hematochezia and the confirmation of the diagnosis can be difficult. The aim of this study is to describe grayscale and color Doppler ultrasound findings in patients with CMA. METHODS: we retrospectively studied 13 infants with CMA. All infants presented severe hematochezia and abdominal pain. All underwent an US study with the diagnosis of allergic colitis. This diagnosis was based on clinical findings, recovery after infant or mother exclusion diets in the case of exclusive breastfeeding and positive oral challenge test. RESULTS: the mean age ranged from 1 to 6 months (mean = 3.53). Seven out of 13 infants (53.8%) had grayscale and color Doppler sonographic repeated after exclusion diet. Twelve out of 13 (92,3%) showed abnormalities at US and CDUS at beginning. The positive findings suggesting colitis were thickened bowel walls and increased vascularity, especially in the descending and sigmoid colon. Colonoscopy and histopathological findings were compatible with allergic colitis. After a diet change the 13 infants recovered and their oral challenge tests were positive. CONCLUSION: Doppler US may be very useful in diagnosing secondary colitis, such as CMA, and to exclude several other abdominal diseases that can emulate this disease.

Cow's milk allergy: color Doppler ultrasound findings in infants with hematochezia.

OBJECTIVE: ultrasound (US) has been an important diagnostic tool to identify several causes of gastrointestinal bleeding. Infants with cow's milk allergy (CMA) may present hematochezia and the confirmation of the diagnosis can be difficult. The aim of this study is to describe grayscale and color Doppler ultrasound findings in patients with CMA. METHODS: we retrospectively studied 13 infants with CMA. All infants presented severe hematochezia and abdominal pain. All underwent an US study with the diagnosis of allergic colitis. This diagnosis was based on clinical findings, recovery after infant or mother exclusion diets in the case of exclusive breastfeeding and positive oral challenge test. RESULTS: the mean age ranged from 1 to 6 months (mean=3.53). Seven out of 13 infants (53.8%) had grayscale and color Doppler sonographic repeated after exclusion diet. Twelve out of 13 (92,3%) showed abnormalities at US and CDUS at beginning. The positive findings suggesting colitis were thickened bowel walls and increased vascularity, especially in the descending and sigmoid colon. Colonoscopy and histopathological findings were compatible with allergic colitis. After a diet change the 13 infants recovered and their oral challenge tests were positive. CONCLUSION: Doppler US may be very useful in diagnosing secondary colitis, such as CMA, and to exclude several other abdominal diseases that can emulate this disease.

Waist circumference in children and adolescents correlate with metabolic syndrome and fat deposits in young adults.

BACKGROUND & AIMS: To determine the relevance of waist circumference (WC) measurement and monitoring in children and adolescents as an early indicator of overweight, metabolic syndrome (MS) and cardiovascular problems in young adults in comparison with visceral and subcutaneous adiposity. METHODS: A cohort study with 159 subjects (51.6% female) started in 1999 with an average age of 13.2 years. In 1999, 2006 and 2008 weight, height, and WC were evaluated. In 2006 blood samples for laboratory diagnosis of MS were added. In 2008 abdominal computed tomography (ACT) to quantify the fat deposits were also added. RESULTS: The WC measured in children and adolescents was strongly correlated with body mass index (BMI) measured simultaneously. A strong correlation was established between WC in 1999 with measures of WC and BMI as young adults. WC strongly correlated with fat deposits in ACT. The WC in 1999 expressed more subcutaneous fat (SAT), while the WC when young adults expressed strong correlation with both visceral fat (VAT) and SAT. The correlation of WC with fat deposits was stronger in females. WC and not BMI in 1999 was significantly higher in the group that evolved to MS. CONCLUSIONS: The WC in children and adolescents was useful in screening patients for MS. WC expressed the accumulation of abdominal fat; especially subcutaneous fat.

Divertículo de Meckel ao Doppler em cores: relato de dois casos / Color Doppler of Meckel's diverticulum: report of two cases

O divertículo de Meckel é a anomalia congênita mais comum do trato gastrintestinal e a hemorragia é a complicação mais frequente. Cintilografia, ultrassonografia modo B e com Doppler, e tomografia computadorizada podem ser utilizadas para detectar complicações. Descrevemos dois casos de divertículo de Meckel complicado detectados à ultrassonografia, cujos achados foram diferentes dos descritos na literatura.

Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract and bleeding is its most frequent complication. Scintigraphy, B-mode and Doppler ultrasonography, and computed tomography may be utilized to detect complications. The present report describes two cases of complicated Meckel's diverticulum detected at ultrasonography whose findings were different from those described in the literature.

Gray-scale and color Doppler ultrasound findings in children with cow's milk allergy.

OBJECTIVE: The objective of our study was to evaluate whether gray-scale and color Doppler ultrasound can reveal intestinal inflammation in infants with cow's milk allergy (CMA). SUBJECTS AND METHODS: This study evaluated the clinical findings and grayscale and color Doppler sonograms of 34 infants. Seventeen 0- to 6-month-old infants with suspected CMA and 17 nonsymptomatic age-matched infants were evaluated by a blinded investigator who determined the percentage of vessel density and the thickness of different parts of the bowel. Clinical and sonographic variables were evaluated in the same regions of bowel considering three time points: presentation, after 4 weeks of feeding only amino acid-based formula, and after challenge test. Likelihood ratios and receiver operating characteristic (ROC) curves were used to define a cutoff point for vascular density percentage. RESULTS: The difference in the percentage of vessel density between patients with CMA (mean, 28.1%) and control infants (mean, 7.77%) was statistically significant. ROC analysis showed that a cutoff point of 18.7% could differentiate between patients with CMA and control infants with 81.8% sensitivity and 94.1% specificity. The area under the curve was 0.941. We found statistical differences in bowel wall thickness between control patients and patients with CMA. CONCLUSION: There was a significant increase in vessel density in infants younger than 6 months with CMA compared with healthy age-matched infants. The most appropriate cutoff point for vessel density was 18.7%. The results of this study suggest that Doppler ultrasound could be used as a screening tool to diagnose CMA.

Análise dos registros de evacuações pela equipe de enfermagem em pacientes com nutrição enteral (NE): redução de registro de diarréias após treinamento / Analysis of records of evacuations by nursing staff in patients with enteral nutrition (EN): reduction of diarrhea after training record / Análisis de los registros de las evacuaciones de personal de enfermería en pacientes con nutrición enteral (NE): reducción de la diarrea después de registro de formación

Objetivo: Comparar os registros de diarréia em pacientes adultos internados, submetidos á nutrição enteral (NE), antes e após treinamento da equipe de enfermagem. Método: Foram avaliados os registros de diarréia realizados pelas equipes de enfermagem, para estes pacientes, durante 30 dias em dois momentos, antes (G1) e após (G2) treinamento, que constava de definição de diarréia (pelo menos 3 fezes líquidas ou semi-líquidas por dia), imagens de evacuações e mudança na forma de registro, com padronização das anotações (o número de evacuações e a quantidade estimada). o intervalo entre as coletas foi de um ano. Resultados: No G1 foram observados 40 pacientes (71+- 17 anos; 52,5% homens), com registro de diarréia em 15 pacientes; 1,66 +- 3,2 dias de diarréia/paciente. com base na definição acima, 10/15 apresentaram efetivamente diarréia. os técnicos descreveram 65 dias com diarréia, mas utilizando a definição padronizada, ocorreu em apenas 18 dias. No G2 foram avaliados 37 pacientes (75,8 +- 13,3 anos; 54,1%homens). foram relatados 0,08 +- 0,27 dias de diarréia/paciente. no G1, o número de dias efetivos de diarréia foi maior que no G2, mas sem diferença estatística. a única diferença estatisticamente significativa foi entre os dias efetivos de diarréia entre os dois grupos (p=0,001). Conclusão: os autores demonstram que a padronização de registros e treinamento da equipe contribuiu para a redução de diagnósticos equiviocados de diarréia.

Objective: To compare the records of diarrhea in hospitalized adult patients, undergoing enteral nutrition (EN), before and after training of nursing staff. Methods: We studied the records of diarrhea made by nursing staff for these patients during 30 days on two occasions, before (G1) and after (G2) training, which included the definition of diarrhea (at least 3 liquid stools or semi net-a day), images of evacuations and change in registration form, with standardization of the notes (the number of bowel movements and estimated). the interval between collections was one year. Results: In G1 were observed 40 patients (71 + - 17 years, 52.5% men) with a record of diarrhea in 15 patients, 1.66 + - 3.2 days of diarrhea / patient. based on the above definition, 10/15 had actually diarrhea. technicians reported 65 days with diarrhea, but using the standard definition, occurred in only 18 days. G2 were assessed 37 patients (75.8 + - 13.3 years, 54.1% men). reported were 0.08 + - 0.27 days of diarrhea / patient. in G1, the actual number of days of diarrhea was higher than in G2, but no statistical difference. the only difference was statistically significant between the actual days of diarrhea between the two groups (p = 0.001). Conclusion: The authors show that the standardization of records and staff training contributed to the reduction of diagnostic equiviocados diarrhea.

Objetivo: Comparar los registros de la diarrea en pacientes adultos hospitalizados, con nutrición enteral (NE), antes y después del entrenamiento del personal de enfermería. Métodos: Se estudiaron los registros de la diarrea por parte del personal de enfermería para estos pacientes durante 30 días en dos ocasiones, antes de (G1) y después (G2) la formación, que incluía la definición de diarrea (heces líquidas por lo menos 3 o semi Net-a-día), las imágenes de las evacuaciones y el cambio en el formulario de inscripción, con la normalización de las notas (el número de evacuaciones intestinales y estimadas). el intervalo entre las colecciones era un año. Resultados: En el G1 se observaron 40 pacientes (71 + - 17 años, hombres 52,5%) con un registro de la diarrea en 15 pacientes, 1.66 + - 3,2 días de diarrea / paciente. sobre la base de la definición anterior, 10/15 había hecho diarrea. técnicos informaron 65 días con diarrea, pero utilizando la definición estándar, se produjo en sólo 18 días. G2 se evaluaron 37 pacientes (75,8 + - 13,3 años, 54,1% hombres). se reportaron 0,08 + - 0,27 días de diarrea / paciente. en el G1, el número real de días de diarrea fue superior en el G2, pero sin diferencia estadística. la única diferencia fue estadísticamente significativa entre los días reales de la diarrea entre los dos grupos (p = 0,001). Conclusión: Los autores demuestran que la normalización de los registros y la capacitación del personal contribuido a la reducción de la diarrea equiviocados diagnóstico.

Esofagite eosinofílica na criança / Eosinophilic esophagitis in the child

Objetivos: Fornecer ao pediatra as informações necessárias para a suspeita clínica, disgnóstico precoce e conduta adquada nos casos acometidos por esofagite eosinofílica esta doença. Fonte de Dados: Foram selecionados, através do Medline, os artigos de periódicos médicos nacionais e internacionais mais relevantes sobre o tema dos últimos 20 anos. Sintese dos dados: São abordados os seguintes tópicos: incidência, etiologia fisiopatologia, genética, sintomatologia, disgnóstico e tratamento, com ênfase especial no tratamento de eliminação, medicamentoso e endoscópico. Conclusões: Esofagite eosinofilica é uma inflamação com infiltrado de eossinofilos, que ocorre de forma isolada no esôfago , onde os sintomas, usualmente, saão confundidos com os da doença por refluxo gastresofágico. A incidência desta doença aumentando nos últimos anos, sendo diagnosticadaatravés da endoscopia disgestivaalta e biópsias. O tratamento consiste em uma dieta de eliminação dos alérgenos envolvidos, assim como costicosteróides tópicos ou sistêmicos.

Graded compression sonography of the colon in the diagnosis of polyps in pediatric patients.

OBJECTIVE: We report seven cases of juvenile polyps detected by graded compression gray-scale and color Doppler sonography in five children with nonspecific symptoms. CONCLUSION: Intestinal polyps can be detected by graded compression gray-scale and color Doppler sonography without colonic preparation. On gray-scale sonography, polyps appeared as spherical or ovoid hypoechoic nodules in the colon lumen. Small cysts were identified inside the nodules. Four polyps had fewer and smaller cysts, whereas three others contained many cysts. A hyperechoic layer surrounding the polyp corresponded to the submucosa. In two patients, the polyp was visualized in the transverse colon and caused a colocolic intussusception, which reduced spontaneously during sonography. Color Doppler sonography showed four hypovascularized and three hypervascularized polyps.

Alimentaçäo no primeiro ano de vida / Alimentation in the first year of life

O primeiro ano de vida é peeríodo de grande desenvolvimento da criança e merece atençäo especial do pediatra, que deve orientar adequadamente a introduçäo de alimentos para o lactente, respeitando sua digestibilidade e desenvolvimento. Os autores reforoam a importância do aleitamento materno exclusivo nos primeiros seis meses e as introduçöes de outros alimentos nos meses seguintes, assim como orientam a alimentaçäo de crianças que näo recebem leite materno. O leite materno é o principal alimento para o lactente no primeiro ano de vida e este deve ser seu alimento exclusivo atéseis meses. Assim permitirá adequado desenvolvimento e prevençäo de doenças. Quando for impossível a amamentaçäo, deve ser dada preferência para as fórmulas lácteas especiais para lactentes e as introduçöes dos alimentos devem respeitar o amadurecimento da criança. Assim podemos propiciar um desenvolvimento harmônico da doença nesta importante fase de sua vida.(au)