What the primary care pediatrician should know about syndromes associated with exposures to mycotoxins

Mycotoxins of Concern in Children and Infant Cereal Food at European Level: Incidence and Bioaccessibility

Cereals are of utmost importance for the nutrition of infants and children, as they provide important nutrients for their growth and development and, in addition, they are easily digestible, being the best choice for the transition from breast milk/infant formula to solid foods. It is well known that children are more susceptible than adults to toxic food contaminants, such as mycotoxins, common contaminants in cereals. Many mycotoxins are already regulated and controlled according to strict quality control standards in Europe and around the world. There are, however, some mycotoxins about which the level of knowledge is lower: the so-called emerging mycotoxins, which are not yet regulated. The current review summarizes the recent information (since 2014) published in the scientific literature on the amounts of mycotoxins in infants’ and children’s cereal-based food in Europe, as well as their behaviour during digestion (bioaccessibility). Additionally, analytical methods used for mycotoxin determination and in vitro methods used to evaluate bioaccessibility are also reported. Some studies demonstrated the co-occurrence of regulated and emerging mycotoxins in cereal products used in children’s food, which highlights the need to adopt guidelines on the simultaneous presence of more than one mycotoxin. Although very little research has been done on the bioaccessibility of mycotoxins in these food products, very interesting results correlating the fiber and lipid contents of such products with a higher or lower bioaccessibility of mycotoxins were reported. LC-MS/MS is the method of choice for the detection and quantification of mycotoxins due to its high sensibility and accuracy. In vitro static digestion models are the preferred ones for bioaccessibility evaluation due to their simplicity and accuracy.

Mycotoxin Exposure during the First 1000 Days of Life and Its Impact on Children’s Health: A Clinical Overview

The first 1000 days of life are very sensitive to any event that alters health programming, and they represent a window for intervention to improve population health. Pregnant women, fetuses, and infants are particularly vulnerable to exposure to food contaminated with mycotoxins. This review aimed to gather data from the literature on mycotoxins exposure during intrauterine life and early childhood, and associated health risks, as assessed through human biomonitoring and mycotoxins occurrence in foods, in different continents. Maternal internal exposure to aflatoxins is associated with fetal growth restriction, while exposure to fumonisins increases the risk of offspring’s neural tube defects. Mycotoxin contamination of breast milk is reported worldwide, but data on adverse effects of the lactational transfer of mycotoxins on infant health are lacking. Young children are exposed to mycotoxins through contaminated infant formulas and baby foods. Both external and internal exposure to aflatoxins and fumonisins in children are reported to be associated with growth impairment. In low-income settings, where other co-factors can affect growth, this association should be interpreted with caution. Further studies on human biomonitoring of mother–infant pairs and young children are needed to guide management strategies aiming to minimize mycotoxin exposure at critical developmental stages.

Natural Occurrence of Deoxynivalenol in Cereal-Based Baby Foods for Infants from Western Poland

The study examined 110 samples of baby products based on rice, wheat, maize and multi-grains available on the western Polish market in order to detect the level of deoxynivalenol (DON) by means of HPLC (high-performance liquid chromatography) with a fluorescence detector (HPLC-FLD). DON was detected in 9.09% of the infant food samples, with an average and maximum level of 107.8 ± 30 and 148 μg/kg, respectively. The highest concentration of DON was detected in food for infants: wheat-based (mean 121 ± 7.07, 4.8%), multi-grain (mean 118 ± 5.65, 4.25%) and maize-based (mean 100 ± 37.96; 35.30%). No high DON content and high estimated daily intake were observed in the analyzed products. However, in order to minimize the harmfulness associated with the presence of DON in food for infants and young children, a risk assessment should be performed based on the monitoring results.

Assessment of Exposure to Mycotoxins in Spanish Children through the Analysis of Their Levels in Plasma Samples

In this study, we present, for the first time in Spain, the levels of 19 mycotoxins in plasma samples from healthy and sick children (digestive, autism spectrum (ASD), and attention deficit hyperactivity (ADHD) disorders) (n = 79, aged 2–16). The samples were analyzed by liquid chromatography-mass spectrometry (triple quadrupole) (LC-MS/MS). To detect Phase II metabolites, the samples were reanalyzed after pre-treatment with β-glucuronidase/arylsulfatase. The most prevalent mycotoxin was ochratoxin A (OTA) in all groups of children, before and after enzyme treatment. In healthy children, the incidence of OTA was 92.5% in both cases and higher than in sick children before (36.7% in digestive disorders, 50% in ASD, and 14.3% in ADHD) and also after the enzymatic treatment (76.6 % in digestive disorders, 50% in ASD, and 85.7% in ADHD). OTA levels increased in over 40% of healthy children after enzymatic treatment, and this increase in incidence and levels was also observed in all sick children. This suggests the presence of OTA conjugates in plasma. In addition, differences in OTA metabolism may be assumed. OTA levels are higher in healthy children, even after enzymatic treatment (mean OTA value for healthy children 3.29 ng/mL, 1.90 ng/mL for digestive disorders, 1.90 ng/mL for ASD, and 0.82 ng/mL for ADHD). Ochratoxin B appears only in the samples of healthy children with a low incidence (11.4%), always co-occurring with OTA. Sterigmatocystin (STER) was detected after enzymatic hydrolysis with a high incidence in all groups, especially in sick children (98.7% in healthy children and 100% in patients). This supports glucuronidation as a pathway for STER metabolism in children. Although other mycotoxins were studied (aflatoxins B1, B2, G1, G2, and M1; T-2 and HT-2 toxins; deoxynivalenol, deepoxy-deoxynivalenol, 3-acetyldeoxynivalenol, 15-acetyldeoxynivalenol; zearalenone; nivalenol; fusarenon-X; neosolaniol; and diacetoxyscirpenol), they were not detected either before or after enzymatic treatment in any of the groups of children. In conclusion, OTA and STER should be highly considered in the risk assessment of mycotoxins. Studies concerning their sources of exposure, toxicokinetics, and the relationship between plasma levels and toxic effects are of utmost importance in children.

Mycotoxin Occurrence, Exposure and Health Implications in Infants and Young Children in Sub-Saharan Africa: A Review

Infants and young children (IYC) remain the most vulnerable population group to environmental hazards worldwide, especially in economically developing regions such as sub-Saharan Africa (SSA). As a result, several governmental and non-governmental institutions including health, environmental and food safety networks and researchers have been proactive toward protecting this group. Mycotoxins, toxic secondary fungal metabolites, contribute largely to the health risks of this young population. In SSA, the scenario is worsened by socioeconomic status, poor agricultural and storage practices, and low level of awareness, as well as the non-establishment and lack of enforcement of regulatory limits in the region. Studies have revealed mycotoxin occurrence in breast milk and other weaning foods. Of concern is the early exposure of infants to mycotoxins through transplacental transfer and breast milk as a consequence of maternal exposure, which may result in adverse health effects. The current paper presents an overview of mycotoxin occurrence in foods intended for IYC in SSA. It discusses the imperative evidence of mycotoxin exposure of this population group in SSA, taking into account consumption data and the occurrence of mycotoxins in food, as well as biomonitoring approaches. Additionally, it discusses the health implications associated with IYC exposure to mycotoxins in SSA.

Ceftriaxone-Associated Biliary and Cardiopulmonary Adverse Events in Neonates: A Systematic Review of the Literature

BACKGROUND

Ceftriaxone is a third-generation cephalosporin with broad-spectrum activity against both Gram-positive and Gram-negative bacteria. Despite its effectiveness, its use for the treatment of infections in neonatal patients has been limited because of concern about its potential toxicity.

OBJECTIVE

Our aim was to review the literature for an association between ceftriaxone and cardiopulmonary events, hyperbilirubinemia, and pseudolithiasis among neonates.

METHODS

We searched PubMed and EMBASE and included studies that evaluated ceftriaxone safety in neonates. Study bias was evaluated in the following domains: exposure measurement, outcome measurement, attrition, generalizability, confounding, statistical analysis, and reporting.

RESULTS

We included nine studies regarding ceftriaxone side effects, primarily spontaneous reports, published case reports, and small case series. Reports of bilirubin displacement attributed to ceftriaxone included increases in serum bilirubin necessitating antibiotic change in a subset of infants after administration of ceftriaxone. One study described self-resolving biliary sludge after ceftriaxone administration in six of 80 infants. Cardiopulmonary adverse events included a report of eight cardiopulmonary events related to concomitant ceftriaxone-calcium infusion, including seven infant deaths. Additional cardiopulmonary events reported included perinatal asphyxia, pulmonary hypertension, and thrombocytosis. However, the available literature had small sample sizes, poor external validity, and inconsistent outcome ascertainment methods, which made it impossible to estimate the magnitude of risk.

DISCUSSION

Concomitant administration of intravenous ceftriaxone and calcium-containing solutions should be avoided in neonates. However, further controlled studies are needed to assess whether bilirubin displacement associated with the use of ceftriaxone is clinically relevant, particularly in healthy term and near-term neonates with mild hyperbilirubinemia.

Activity of Zearalenone in the Porcine Intestinal Tract

This study demonstrates that low doses (somewhat above the No Observed Adverse Effect Level, NOAEL) of the mycoestrogen zearalenone (ZEN) and its metabolites display multispecificity towards various biological targets in gilts. The observed responses in gilts were surprising. The presence of ZEN and zearalenols (ZELs) did not evoke a response in the porcine gastrointestinal tract, which was attributed to dietary tolerance. Lymphocyte proliferation was intensified in jejunal mesenteric lymph nodes, and lymphocyte counts increased in the jejunal epithelium with time of exposure. In the distal digestive tract, fecal bacterial counts decreased, the activity of fecal bacterial enzymes and lactic acid bacteria increased, and cecal water was characterized by higher genotoxicity. The accompanying hyperestrogenism led to changes in mRNA activity of selected enzymes (cytochrome P450, hydroxysteroid dehydrogenases, nitric oxide synthases) and receptors (estrogen and progesterone receptors), and it stimulated post-translational modifications which play an important role in non-genomic mechanisms of signal transmission. Hyperestrogenism influences the regulation of the host's steroid hormones (estron, estradiol and progesteron), it affects the virulence of bacterial genes encoding bacterial hydroxysteroid dehydrogenases (HSDs), and it participates in detoxification processes by slowing down intestinal activity, provoking energy deficits and promoting antiporter activity at the level of enterocytes. In most cases, hyperestrogenism fulfils all of the above roles. The results of this study indicate that low doses of ZEN alleviate inflammatory processes in the digestive system, in particular in the proximal and distal intestinal tract, and increase body weight gains in gilts.

Changes in the metabolic profile and body weight of pre-pubertal gilts during prolonged monotonic exposure to low doses of zearalenone and deoxynivalenol

The aim of this study was to determine whether exposure to low doses of ZEN + DON induces changes in serum biochemical and hematological parameters in pre-pubertal gilts. In the evaluated groups, minor but statistically significant changes were noted in selected serum biochemical parameters, including glucose, total cholesterol, ALT, AST, AP, total bilirubin, P_in, Fe, K and Cl, and in hematological parameters, including WBC, eosinophils, basophils, monocytes, Ht, Hb, MCHC, HDW and PLT. A statistical analysis of the results revealed significant differences between groups in the values of WBC, eosinophils, basophils, Hb, Ht, PLT, glucose, ALT, AP, total bilirubin, Fe and K. Change trends were noted mainly in weeks II and V-VI. An analysis of the metabolic profile of pre-pubertal gilts exposed to ZEN + DON indicates that homeostasis and biotransformation of ZEN + DON can be toned down at the expense of the animals' energy reserves. Body weight gains were lower in group E, and BW gains were not observed in weeks II and VI. The activity levels of gilts decreased in the first weeks of exposure (I and II), but the drop was minimized by a compensatory effect, or in the last two weeks of exposure due to nutrient deficiency or insufficient supply of protein and energy with feed and feed additives, which decreased BW gains. Low doses of mycotoxins induce completely different changes in the metabolic test than higher doses. The above can probably be attributed to: (i) a negative compensatory effect, (ii) initiation of adaptive mechanisms and stimulation of the immune system, probably due to the allergizing properties of mycotoxins, (iii) excessive loss of energy and protein due to more effective feed utilization, or (iv) involvement in detoxification processes which leads to fatigue. Depending on the body's energy stores, the above processes tend to tone down the biotransformation of low doses of the examined mycotoxins but in the present study, the BW of gilts did not increase under exposure to a combination of ZEN + DON.

Risk assessment for changes in the metabolic profile and body weights of pre-pubertal gilts during long-term monotonic exposure to low doses of zearalenone (ZEN)

The aim of the study was to examine whether the process of exposure to low doses of ZEN generates changes in the hematological and biochemical image of blood serum. During the experiment, pre-pubertal gilts (up to 25kg) were administered per os ZEN at a dose of 40μg/kg BW (Group E, n=18) or placebo (Group C, n=21) on a daily basis for 42days. Blood samples for investigation were collected seven times at intervals of one week. In the experimental groups, slight but statistically significant changes in the values of selected biochemical blood indices such as glucose, ALT, P_in, total protein and Fe, or in hematological indices such as RBC, MCV, PLT, WBC, basophils, eosinophils and monocytes were observed. Based on statistical analysis between the groups, differences in the values of WBC, basophils, peroxidase negative cells, Hb, Ht, MCV, HDW, glucose, ALT, AP, total protein, iron or potassium were found. In Group E, decreasing trends in the values of PLT and glucose, and increasing trends in the values of total protein, P_in, Na and Cl were found. The described situations occurred during the last three weeks of exposure. Low levels of exposure to ZEN lead to completely different changes in the metabolic profile than those resulting from higher doses of the toxin. The stimulatory effect of mycotoxins, observed in initial stages of exposure, is eliminated when the compensatory response and adaptive mechanisms are triggered, and due to excessive loss of energy, which may point to more efficient feed utilization and/or detoxification processes. The values of body weight gain obtained in Group E were monotonically higher in four out of the six investigated weeks of exposure. The above changes were accompanied by a decrease in glucose concentrations and higher total protein levels (a rising tendency), which could have affected the rate of body weight gain.

Mycotoxins and child health: the need for health risk assessment

The occurrences of mycotoxins as food contaminants in different localities particularly in developing countries and the inevitable exposure of populations and children to these toxins with probable adverse outcomes need be scientifically and systematically assessed. Health risk assessment developed in the 1980s is separate from risk management, both with risk communication form the risk analysis framework adopted by the World Health Organization. The process contributes increasingly to policy development, public health decision making, the establishment of mycotoxin regulations and research planning. However, the exercise of the risk assessment structured approach is not simple and is faced up to lack of data, capable infrastructure facilities and need for trained personnel and resources. Furthermore, adopted methodologies need be developed focusing on child characteristics and health concerns.