Paediatrics: Edited by Berthold V. Koletzko and Raanan Shamir
The paediatric section in this issue of the journal covers a broad spectrum of timely and relevant topics. Malnutrition remains a major challenge for global child health. Imdad et al. (Karachi, Pakistan; pp. 000–000) review the evidence base for preventing primary malnutrition in children from poor populations. They conclude that multiple micronutrient supplementation of pregnant women can reduce maternal anaemia and low birth weight of their infants, but combined supplementation of multiple micronutrients with protein and energy is more effective than multiple micronutrient supplementation alone. Although breast-feeding by HIV-infected mothers is not recommended in affluent countries, in poor countries, exclusive breast-feeding for 6 months is now recommended if mother or infant receive effective antiretroviral therapy. Home fortification of complementary foods was shown to reduce the occurrence of anaemia in infants, and multiple micronutrient supplements combined with lipid-based supplements improve the growth of young children. Ready-to-use therapeutic foods (RUTF) are effective in treating acute malnutrition in communities. Zinc supplementation is associated with reduction in diarrhoea and respiratory disease morbidity and improves linear growth. Vitamin A supplementation decreases incidence of diarrhoea and measles. Water supply, sanitation and hygiene are important for prevention of malnutrition because of their direct impact on infectious disease. Overall, today there is ample evidence for effective preventive approaches, but a remaining challenge is their broad implementation.
With regard to the other extreme of current nutritional challenges in paediatrics, Keidar et al. (Jerusalem, Israel; pp. 000–000) report on bariatric surgery for obese adolescents. On the basis of the limited evidence from one randomized controlled trial and several case series, mainly on gastric banding and gastric bypass, they conclude that surgery performed on appropriately selected obese adolescents and by experienced surgical teams is relatively safe and achieves effective weight loss as well as improvements in obesity-related comorbidities. However, adverse psychological effects appear more common than in adult patients. Further work is needed to establish appropriate patient selection criteria, choice of the procedures and conditions of preoperative and postoperative patient care.
Nutritional prevention of congenital defects is discussed by Czeizel and Bánhidy (Budapest, Hungary; pp. 000–000) who describe that periconceptional supplementation of folic acid or folic acid-containing multivitamins effectively reduces the occurrence of neural-tube defects as well as congenital cardiovascular abnormalities. The available data indicate a higher preventive efficacy of multivitamins, as compared to folic acid alone. Although the optimal preventive vitamin dose is presently not known with certainty, this knowledge is not mandatory for preventive application, given the broad therapeutic safety range of the intervention. However, implementation of the available knowledge into practice is far less than satisfactory, and more efforts appear necessary for effective prevention of congenital abnormalities.
Two further manuscripts address specific challenges of prematurely born infants, a population with very high susceptibility to nutritional problems. Fewtrell (London, UK; pp. 000–000) reviews the limited evidence base on the effects of early life nutrition on bone heath in adulthood. Infants born prematurely are deprived of much of the normal intrauterine bone mineral accretion, and postnatal bone mineralization falls far short of intrauterine rates. Large differences in mineral intake during the neonatal period had clear effects on early biochemical markers such as alkaline phosphatase activity, but no detectable effect on bone mass or bone turnover in early adulthood. In contrast, neonatal human milk feeding resulted in higher adult bone mass in spite of its very low mineral content. These findings lend support to encouraging the use of fortified human milk feeding to preterm babies, although the effect of the fortification on bone health is yet to be determined.
Human milk feeding has also been reported to reduce the incidence of necrotizing enterocolitis (NEC), a very serious disorder with high morbidity and mortality that affects about 4–6% of infants born with a birth weight less than 1500 g. Mihatsch (Schwäbisch Hall, Germany; pp. 000–000) reviews the evidence for benefits of supplementing probiotic bacteria for reducing the incidence of severe NEC and mortality in preterm infants, a topic that currently is the subject of heated debates among neonatologists. He emphasizes that meta-analyses across available trials may be misleading because heterogeneous interventions were included; therefore, generalized conclusions appear inappropriate. He reports that the 16 available randomized controlled trials on this subject studied 12 different probiotic preparations. Although certain probiotics may be beneficial for preventing severe NEC, he concludes that each individual probiotic intervention should be evaluated separately.
It is our hope that the readership of the journal, including those who do not deal with paediatric patients on a daily basis, will find these insightful reviews stimulating and useful.