The impact of dietary protein in complementary foods on infant growth and iron status in a population facing double burden of malnutrition

Dietary protein is a key macronutrient for infant growth, especially during complementary feeding (CF). Inadequate intake contributes to undernutrition. However, evidence from high-income countries suggests high protein intake, especially of animal-based protein (ABP), may increase obesity risk. Determining optimal protein intake and sources during CF is thus challenging, particularly in lower-income settings where the double burden malnutrition (DBM; co-existence of under- and overnutrition) is common; and considering that animal-source foods are a good source of iron during this period of high requirements. This thesis aimed to investigate how protein quantity and source during CF influence infant growth and iron status in a setting experiencing the DBM, and to explore potential mechanisms. A multi-centre, prospective cohort was conducted in 145 healthy-term infants in Chiang Mai, Thailand. Dietary intakes and anthropometric measurements were collected at 6, 9 and 12M. At 12M, blood samples were analysed for iron status, serum IGF-1, IGFBP-3 and plasma branched-chain amino acids (BCAA). Protein consumption exceeded recommendations at 9-12M. Both dairy and non-dairy ABP were positively associated with weight-for-age and weight-for-length z-scores after adjusting for type of milk-feed and non-protein calories, with no effect on linear growth. Dairy ABP showed a stronger association than non-dairy ABP, consistent with its higher association with IGF-1, IGFBP-3 and BCAA. Protein intake did not differ significantly between iron-sufficient versus iron-deficient (ID) infants, but consumption of ≥ 3 tablespoons of liver/week was associated with a nearly 80% reduction in ID. The findings highlight differential effects of protein source on infant growth and iron status. Unlike dairy protein, non-diary ABP may promote growth without greatly increasing IGF-1, IGFBP-3 and BCAA which are implicated in increased obesity risk whilst also representing a good source of iron. The findings could help develop interventions for testing in randomised trials to establish causal relationships and mechanisms and contribute to improving CF protein recommendations

Prevalence of Hospital Malnutrition at Admission and Outcomes in Pediatric Patients

Background: Hospitalized children are at risk of malnutrition and vulnerable for many adverse outcomes.Objectives: This study aimed to determine the prevalence of hospital malnutrition in pediatric patients admitted at Chiang Mai University (CMU) hospital and evaluate correlation between malnutrition and outcomes including length of hospital stay (LOS), total hospital cost and mortality.Methods and Study Design: A prospective cohort study was conducted at CMU hospital. Patients aged 1 month to 15 year-old who admitted to general pediatric wards were included. Demographic data, anthropometric assessments including weight, length/height and outcomes were collected. Malnutrition was classified by the WHO growth reference.Results: A total of 217 patients with mean age 68.8 ± 53.8 month-old were analyzed. Majority of them were male (65.4%) while leading diagnosis were oncologic, infectious and congenital heart diseases. The prevalence of all malnutrition was 59.9%. According to the WHO classification, percentages of the patients who were stunted, wasted, both of stunted and wasted, and overweight were 29.9%, 9.2%, 17.1%, and 3.7%, respectively. Moreover, compared to previous study of this center in 1985, more than half of hospitalized children have still assessed as under-malnourished patients. For the hospital outcomes, wasting regardless of stunting had significantly longer LOS (8 vs 5 days, p = 0.001) and higher hospital expenditure (37,283.0 vs 23,630.0 Baht, p = 0.004) while mortality was not different.Conclusions: The prevalence of malnutrition in hospitalized children is common and remains unchanged. Acute malnutrition significantly impact on total hospital cost and prolong LOS comparing with other groups

Interventions to Improve Breastfeeding Outcomes in Late Preterm and Early Term Infants

BACKGROUND: Late preterm infants (LPIs; born at 340/7 to 366/7 gestational weeks) and early term infants (ETIs; 370/7 to 386/7 gestational weeks) are at higher risk of morbidity and mortality compared with more mature infants. Breastfeeding can reduce these risks, but feeding difficulties are common among these infants and breastfeeding rates are low. We conducted a systematic review to identify the interventions available to improve any breastfeeding, exclusive breastfeeding, or breast milk yield. METHODS: A literature search was performed up to February 23, 2022, using MEDLINE, CINAHL, Embase, and Google Scholar, and nine articles were included. Only one article was a randomized controlled trial, and only one included ETIs. The remaining articles were quasi-experimental and included only LPIs. Outcomes included breastfeeding duration, breastfeeding exclusivity, and/or breast milk production (volume) before 6 months actual age. RESULTS: Professional support significantly improved exclusive breastfeeding rates. A breastfeeding education program delivered at the hospital with weekly telephone follow-up postdischarge significantly increased breastfeeding rates. Neither cup feeding nor early discharge (with in-home lactation support) improved breastfeeding rates, whereas rooming-in (versus direct admission to the neonatal intensive care unit) worsened exclusive breastfeeding rates. DISCUSSION: This is the first systematic review to identify interventions available for both LPIs and ETIs. Overall, there are limited studies that investigate interventions promoting breastfeeding in these populations. However, breastfeeding support delivered by health care professionals seems to improve breastfeeding rates. The main limitations are the lack of randomization, blinding, and adjustment for confounding variables. Experimental studies with robust methodological design are needed

Quantity and Source of Protein during Complementary Feeding and Infant Growth: Evidence from a Population Facing Double Burden of Malnutrition

Background: While high protein intake during infancy may increase obesity risk, low qualities and quantities of protein contribute to undernutrition. This study aimed to investigate the impact of the amount and source of protein on infant growth during complementary feeding (CF) in a country where under- and overnutrition co-exist as the so-called the double burden of malnutrition. Methods: A multicenter, prospective cohort was conducted. Healthy term infants were enrolled with dietary and anthropometric assessments at 6, 9 and 12 months (M). Blood samples were collected at 12M for IGF-1, IGFBP-3 and insulin analyses. Results: A total of 145 infants were enrolled (49.7% female). Animal source foods (ASFs) were the main protein source and showed a positive, dose–response relationship with weight-for-age, weight-for-length and BMI z-scores after adjusting for potential confounders. However, dairy protein had a greater impact on those parameters than non-dairy ASFs, while plant-based protein had no effect. These findings were supported by higher levels of IGF-1, IGFBP-3 and insulin following a higher intake of dairy protein. None of the protein sources were associated with linear growth. Conclusions: This study showed the distinctive impact of different protein sources during CF on infant growth. A high intake of dairy protein, mainly from infant formula, had a greater impact on weight gain and growth-related hormones

Impact of complementary feeding on obesity risk

PURPOSE OF REVIEW: To discuss recent evidence on the influence of complementary feeding (CF) timing, content and feeding methods on childhood obesity risk. RECENT FINDINGS: The evidence-base is limited by heterogeneity, risk of bias and the predominance of observational studies. The content of the diet and feeding practices are more influential than timing for obesity risk. There is limited evidence that CF introduction before 4 months may be associated with increased risk. Intake of animal protein, particularly dairy protein, may contribute to rapid weight gain; protein from infant/follow-on formula shows the most robust association with later obesity risk. Evidence linking sugar intake to obesity risk is limited, but intake should be as low as possible given there is no nutritional requirement. Responsive feeding (RF) practices may promote appropriate infant growth and reduce risk. The effect of baby-led weaning (BLW) is inconclusive. SUMMARY: Recent evidence supports current recommendations to avoid high protein intakes, especially from infant/follow-on formula, for infants in high income countries; and to promote RF practices for all infants. Studies in low- and middle-income countries are required to define optimal CF practices given increasing rates of child obesity alongside double-burden malnutrition

Hypoalbuminaemia at admission predicts the poor outcomes in critically ill children

  BACKGROUND: Hypoalbuminaemia at admission is a common finding in patients admitted to the Paediatric Intensive Care Unit (PICU) and it is thought that this may predict morbidity and mortality. METHODS: A retrospective study was conducted in the tertiary hospital. The medical records of critically ill children were reviewed. The data were analyzed for the prevalence of hypoalbuminaemia and outcomes. RESULTS: Two hundred and two patients were included in the analysis. The incidence of hypoalbuminaemia at admission was 57.9%. These patients had a mortality rate 4 times greater (adjusted odds ratio 3.8; 95% CI: 1.4–10.0), a longer length of PICU stay (8.6 vs. 6.7 days, P = 0.04) and a longer period on a ventilator (5.9 vs. 3.9 days, P = 0.04) than patients with normal albumin levels. CONCLUSIONS: Hypoalbuminaemia at admission was a predictive factor of poor outcome in critically ill children. It is associated with a higher mortality, a longer length of stay in the PICU, as well as longer ventilator use.    BACKGROUND: Hypoalbuminaemia at admission is a common finding in patients admitted to the Paediatric Intensive Care Unit (PICU) and it is thought that this may predict morbidity and mortality. METHODS: A retrospective study was conducted in the tertiary hospital. The medical records of critically ill children were reviewed. The data were analyzed for the prevalence of hypoalbuminaemia and outcomes. RESULTS: Two hundred and two patients were included in the analysis. The incidence of hypoalbuminaemia at admission was 57.9%. These patients had a mortality rate 4 times greater (adjusted odds ratio 3.8; 95% CI: 1.4–10.0), a longer length of PICU stay (8.6 vs. 6.7 days, P = 0.04) and a longer period on a ventilator (5.9 vs. 3.9 days, P = 0.04) than patients with normal albumin levels. CONCLUSIONS: Hypoalbuminaemia at admission was a predictive factor of poor outcome in critically ill children. It is associated with a higher mortality, a longer length of stay in the PICU, as well as longer ventilator use

Comparison of 24-Hour Recall and 3-Day Food Records during the Complementary Feeding Period in Thai Infants and Evaluation of Plasma Amino Acids as Markers of Protein Intake

Background: An accurate and reliable measurement of nutrient intake is the first and foremost step in order to optimise infant nutrition and evaluate its impact on health outcomes. However, research on the validity of dietary assessment tools used during the weaning period is limited, especially in lower-middle income countries. The primary aim of this study was to evaluate relative validity of a 24-h recall method (24-HR) using a 3-day food record (3-DFR). A secondary aim was to investigate association between protein intake from 3-DFR and plasma amino acids as a potential protein biomarker. Methods A multicentre, prospective cohort study was conducted in Chiang Mai, Thailand from June 2018 to May 2019. Food consumption data were collected in healthy infants using 24-HR and 3-DFR at 9 and 12 months of age. Blood samples were obtained at 12 months (M). Plasma amino acids were analysed using high performance liquid chromatography. Results Of 145 infants, 49% were female. At group level, paired t-tests/Wilcoxon signed rank tests did not show significant differences between average nutrient intakes from the 2 dietary assessment methods, except for vitamin A and vitamin C. Weighted kappa (Kw) was acceptable for all nutrients, except for vitamin A intake at 9 M (Kw = 0.15). The Bland–Altman analyses were unbiased for most nutrients with variable limits of agreement. At individual level, correlation coefficients (r) ranged from acceptable to excellent (r = 0.37–0.87) while cross-classifications showed acceptable outcomes, except for vitamin A. Multivariate analyses showed significant associations between protein intake at 12 M from the 3-DFR and plasma concentrations of branched-chain amino acids (BCAA) and essential amino acids (EAA), even after adjusting for gender, milk feeding type and energy intake. Conclusions For infants aged 9–12 M, a 24-HR can be used as a more practical alternative to a 3-DFR for most nutrients although caution is required for some micronutrients, especially vitamin A. A repeated interview might further improve the accuracy. Furthermore, protein intake, particularly animal-based protein, significantly predicted plasma BCAA and EAA concentrations regardless of gender, type of milk feeding and energy consumption