[Processed baby foods for infants and young children: a dietary advance? A position paper by the Committee on Nutrition of the French Society of Paediatrics]. / Les aliments industriels (hors laits et céréales) destinés aux nourrissons et enfants en bas âge : un progrès diététique ?

Processed baby foods designed for infants (4-12 months) and toddlers (12-36 months) (excluding infant formula, follow-on formula, the so-called growing-up milks, and cereal-based foods for infants), which are referred to as baby foods, are specific products defined by a European regulation (Directive 2006/125/CE). According to this Directive, such foods have a composition adapted to the nutritional needs of children of this age and should comply with specifications related to food safety in terms of ingredients, production processes, and prevention of infectious and toxicological hazards. Hence, they differ from ordinary foods and from non-specific processed foods. This market segment includes the full range of foods that can be part of children's diet: dairy products (dairy desserts, yoghurts, and fresh cheese), sweet products (nondairy desserts, fruit, and drinks), and salty products (soups, vegetable-based foods, meat, fish, and full dishes). This market amounted to 89,666 MT in France in 2011 and 83,055 MT in 2010 (a total of 325,524 MT in the 27 countries of the European Union in 2010, including 90,438 MT in Germany, 49,144 MT in Spain, and 40,438 MT in Italy). The consumption of baby foods in France varies with infant age and parental choice. Baby foods account for 7 % of total energy intake at 4-5 months, 28 % at 6-7 months, 27 % at 8-11 months, 17 % at 1-17 months, and 11 % at 18-24 months. Among parents, 24 % never offer their children any baby foods, 13 % do so 1-3 days/week and 63 % 4-7 days/week. Among consumers, 55 % of children eat more than 250 g/day of baby foods. As baby foods only account for a minor fraction of overall food intake, their impact on the quality of young children's diet is much less than that of growing-up milks, particularly for preventing insufficient iron and vitamin D intake. Their consumption, however, has an indirect benefit on the nutritional quality of the diet and on food safety, particularly regarding toxicological hazards, as it postpones the introduction of non-specific processed foods, which are inadequate for this age group owing to both their nutritional composition and lower food safety control. Baby foods represent a family of products meeting parents' expectations and adapted to infants and young children. They are clearly beneficial in terms of food safety, but the nutritional benefit to be expected from their consumption is minimal: their main advantage is postponing or decreasing the consumption of non-specific industrially processed foods.

Vitamin D: still a topical matter in children and adolescents. A position paper by the Committee on Nutrition of the French Society of Paediatrics.

The aims of the present position paper by the Committee on Nutrition of the French Society of Paediatrics were to summarize the recently published data on vitamin D in infants, children and adolescents, i.e., on metabolism, physiological effects, and requirements and to make recommendations on supplementation after careful review of the evidence. Scientific evidence indicates that calcium and vitamin D play key roles in bone health. The current evidence, limited to observational studies, however, does not support other benefits for vitamin D. More targeted research should continue, especially interventional studies. In the absence of any underlying risk of vitamin D deficiency, the recommendations are as follows: pregnant women: a single dose of 80,000 to 100,000 IU at the beginning of the 7th month of pregnancy; breastfed infants: 1000 to 1200 IU/day; children less than 18 months of age, receiving milk supplemented with vitamin D: an additional daily dose of 600 to 800 IU; children less than 18 months of age receiving milk not supplemented with vitamin D: daily dose of 1000 to 1200 IU; children from 18 months to 5 years of age: 2 doses of 80,000 to 100,000 IU every winter (November and February). In the presence of an underlying risk of vitamin D deficiency (dark skin; lack of exposure of the skin to ultraviolet B [UVB] radiation from sunshine in summer; skin disease responsible for decreased exposure of the skin to UVB radiation from sunshine in summer; wearing skin-covering clothes in summer; intestinal malabsorption or maldigestion; cholestasis; renal insufficiency; nephrotic syndrome; drugs [rifampicin; antiepileptic treatment: phenobarbital, phenytoin]; obesity; vegan diet), it may be justified to start vitamin D supplementation in winter in children 5 to 10 years of age as well as to maintain supplementation of vitamin D every 3 months all year long in children 1 to 10 years of age and in adolescents. In some pathological conditions, doses of vitamin D can be increased. If necessary, the determination of 25(OH) vitamin D serum concentration will help determine the level of vitamin D supplementation.

Dietary treatment of cows' milk protein allergy in childhood: a commentary by the Committee on Nutrition of the French Society of Paediatrics.

The diagnosis of cows' milk protein allergy (CMPA) requires first the suspicion of diagnosis based on symptoms described in the medical history, and, second, the elimination of cows' milk proteins (CMP) from the infant's diet. Without such rigorous analysis, the elimination of CMP is unjustified, and sometimes harmful. The elimination diet should be strictly followed, at least until 9-12 months of age. If the child is not breast fed or the mother cannot or no longer wishes to breast feed, the first choice is an extensively hydrolysed formula (eHF) of CMP, the efficacy of which has been demonstrated by scientifically sound studies. If it is not tolerated, an amino acid-based formula is warranted. A rice protein-based eHF can be an alternative to a CMP-based eHF. Soya protein-based infant formulae are also a suitable alternative for infants >6 months, after establishing tolerance to soya protein by clinical challenge. CMPA usually resolves during the first 2-3 years. However, the age of recovery varies depending on the child and the type of CMPA, especially whether it is IgE-mediated or not, with the former being more persistent. Once the child reaches the age of 9-12 months, an oral food challenge is carried out in the hospital ward to assess the development of tolerance and, if possible, to allow for the continued reintroduction of CMP at home. Some children with CMPA will tolerate only a limited daily amount of CMP. The current therapeutic options are designed to accelerate the acquisition of tolerance thereof, which seems to be facilitated by repeated exposure to CMP.

[Dietetic treatment of cow's milk protein allergy]. / Prise en charge diététique de l'allergie aux protéines du lait de vache.

New data on food allergy has recently changed the management of children with cow's milk protein allergy (CMPA). The diagnosis of CMPA first requires the elimination of cow's milk proteins and then an oral provocation test following a standard diagnostic procedure for food allergy, without which the elimination diet is unjustified and sometimes harmful. Once the diagnosis is made, the elimination diet is strict, at least until the age of 9-12 months. If the child is not breastfed or the mother cannot or no longer wishes to breastfeed, the first choice is a formula based on extensive hydrolyzate of cow's milk (eHF), provided that its effectiveness has been demonstrated. When eHF fails, a formula based on amino acids is warranted. eHF based on rice protein hydrolysates is an alternative to cow's milk eHF. Infant formulas based on soy protein can be used after the age of 6 months, after verification of good clinical tolerance to soy. Most commonly, CMPA disappears within 2 or 3 years of life. However, the age of recovery varies depending on the child and the type of CMPA, and whether or not it is IgE-mediated, the first being more sustainable. When the child grows, a hospital oral provocation test evaluates the development of tolerance and, if possible, authorizes continuing the reintroduction of milk proteins at home. Some children with CMPA will tolerate only a limited daily amount of cow's milk proteins. The current therapeutic options are designed to accelerate the acquisition of tolerance, which seems facilitated by regular exposure to cow's milk proteins.

[Place of milks in the course of food diversification in infants and juvenile children in France]. / Place des laits au cours de la diversification alimentaire des nourrissons et enfants en bas âge en France.

Food diversification in infants and children is associated with major changes in both macronutrient and micronutrient intake. During this nutritional transition period, it is essential to continue to meet their nutritional needs for maintaining health and reducing morbidity. It has long been known that breast milk, when associated with an adequate intake of non-dairy food, is the ideal milk for meeting this objective. Clearly, all mothers do not want or cannot carry on breastfeeding throughout this period of diversification, and bottle-feeding has to be used. There is very little information on how a nutritionally adequate diet should be formulated in this situation. A recent French study provides new data however. It shows that a diet based on cow's milk is likely, in a high percentage of infants and young children, to give rise to an insufficient intake of essential fatty acids, iron, vitamin C and vitamin D. The use of supplemented formulas as a substitute for cow's milk avoids these nutritional risks, with the exception of vitamin D. It appears therefore appropriate during the period of food diversification to recommend the use of infant formula for infants less than 6-months-old, follow-on formula from 6 to 12 months, and fortified toddler milk from 12 to 36 months.

[Childhood diet and cardiovascular risk factors]. / Alimentation de l'enfant et facteurs de risque cardiovasculaire.

Atherosclerosis begins during childhood. From childhood, a strong relation has been shown between the prevalence and extent of the asymptomatic atherosclerosis lesions and cardiovascular risk factors such as elevation in body mass index, blood pressure and plasma lipid concentrations. These risk factors depend not only on the subjects' genetic predisposition, but also on environmental parameters, particularly diet. The Committee on Nutrition reviewed the scientific basis of dietary recommendations for children that could reduce the risk factors and thereby, reduce the risk of coronary heart disease in later life: the effects of prenatal nutrition; the beneficial consequences of breast-feeding on later levels of cholesterolemia, blood pressure and corpulence; the role of dietary lipids on plasma lipid concentration, of salt and potassium on blood pressure, and of lifestyle on corpulence.

[Folic acid and prevention of neural tube closure defects: the question is not solved yet]. / Prévention par l'acide folique des défauts de fermeture du tube neural: la question n'est toujours pas réglée.

Between 1981 and 1996, several interventional studies proved the efficacy of periconceptional folic acid supplementation in the prevention of neural tube closure defects (NTCD), first in women at risk (with a previous case of NTCD) and also in women of the general population in age to become pregnant. The poor observance of this supplementation led several countries (USA, Canada, Chile...) to decide mandatory folic acid fortification of cereals, which permitted a 30% (USA) to 46% (Canada) reduction in the incidence of NTCD. Moreover, this benefit was accompanied by a diminished incidence of several other malformations and of stroke and coronary accidents in elderly people. However, several papers drew attention to an increased risk of colorectal and breast cancer in relation with high blood folate levels and the use of folic acid supplements. A controlled interventional study showed a higher rate of recurrence of colic adenomas and a higher percentage of advanced adenomas in subjects receiving 1mg/day of folic acid. A recent study demonstrated an abrupt reversal of the downward trend in colorectal cancer 1 year after the beginning of cereal folic acid fortification in the USA and Canada. Two studies also reported impaired cognitive functions in elder persons with defective vitamin B(12) status. Taken in aggregate, these studies question the wisdom of a nationwide, mandatory, folic acid fortification of cereals. As of today, despite their limited preventive efficacy, a safe approach is to keep our current French recommendations and to increase the awareness of all caregivers, so as to improve the observance of these recommendations.

[Feeding during the first months of life and prevention of allergy]. / Alimentation des premiers mois de vie et prévention de l'allergie.

Allergy consists in the different manifestations resulting from immune reactions triggered by food or respiratory allergens. Both its frequency and severity are increasing. The easiest intervention process for allergy prevention is the reduction of the allergenic load which, for a major allergen such as peanuts, has to begin in utero. The primary prevention strategy relies first on the detection of at risk newborns, i.e. with allergic first degree relatives. In this targeted population, as well as for the general population, exclusive breastfeeding is recommended until the age of 6 months. The elimination from the mother's diet of major food allergens potentially transmitted via breast milk may be indicated on an individual basis, except for peanut, which is systematically retrieved. In the absence of breastfeeding, prevention consists in feeding at-risk newborns until the age of 6 months with a hypoallergenic formula, provided that its efficiency has been demonstrated by well-designed clinical trials. Soy based formulae are not recommended for allergy prevention. Complementary feeding should not be started before the age of 6 months. Introduction of egg and fish into the diet can be made after 6 months but the introduction of potent food allergens (kiwi, celery, crustaceans, seafood, nuts, especially tree nuts and peanuts) should be delayed after 1 year. This preventive policy seems partially efficacious on early manifestations of allergy but does not restrain the allergic march, especially in its respiratory manifestations. Probiotics, prebiotics as well as n-3 fatty polyunsaturated acids have not yet demonstrated any definitive protective effect.

[Feeding of infants based on age. Practice guidelines]. / Alimentation du nourrisson et de l'enfant en bas âge. Réalisation pratique.

This paper presents practical guidelines for nutrition and feeding of infants and toddlers including vitamin D, vitamin K and fluoride supplementations and preventive measures at risk for food allergy based on family history.

[Nutritional treatment of acute diarrhea in an infant and young child]. / Traitement nutritionnel des diarrhées aiguës du nourrisson et du jeune enfant.

This paper written by the Comité de nutrition de la Société française de pédiatrie is specially devoted to the nutritional treatment of infant and child acute diarrhea, i.e. oral rehydration with salts solution and feeding. It complements an article on drug therapy of child acute diarrhea written by the Groupe francophone d'hépatologie, gastroentérologie et nutrition pédiatriques, and published in this same issue of the Archives de pédiatrie.