A kwashiorkor case due to the use of an exclusive rice milk diet to treat atopic dermatitis

Cow's Milk in Human Nutrition and the Emergence of Plant-Based Milk Alternatives

Cow's milk is considered a complete food, providing high-quality protein and essential micronutrients, including vitamins and minerals. For medical reasons or as a lifestyle choice, consumers are replacing cow's milk with plant-based milk alternatives (PBMA); some perceive them as healthier alternatives to cow's milk due to their low saturated fatty acid content and no cholesterol content. However, the nutritional composition of PBMA is quite variable between different types and even within, which makes a comparison with cow's milk a complex issue. Furthermore, the consumption of PBMA has been associated with the development of some diseases in infants and children. Meanwhile, the consumption of cow's milk in human health is a controversial issue since it has been associated with a favorable effect in some diseases (such as obesity, type 2 diabetes, and Alzheimer's) and a negative effect in others (such as prostate cancer risk and Parkinson's disease); while in some diseases, there is no consensus in the cow's milk consumption effect. The aim of this review is to make a nutritional comparison of cow's milk with PBMA and to clarify the potential health issues related to their consumption.

Vegan nutrition: a preliminary guide for health professionals

Since the beginning of the 21st century, interest in vegan diets has been rapidly increasing in most countries. Misconceptions about vegan diets are widespread among the general population and health professionals. Vegan diets can be health-promoting and may offer certain important advantages compared to typical Western (and other mainstream) eating patterns. However, adequate dietary sources/supplements of nutrients of focus specific to vegan diets should be identified and communicated. Without supplements/fortified foods, severe vitamin B12 deficiency may occur. Other potential nutrients of focus are calcium, vitamin D, iodine, omega-3 fatty acids, iron, zinc, selenium, vitamin A, and protein. Ensuring adequate nutrient status is particularly important during pregnancy, lactation, infancy, and childhood. Health professionals are often expected to be able to provide advice on the topic of vegan nutrition, but a precise and practical vegan nutrition guide for health professionals is lacking. Consequently, it is important and urgent to provide such a set of dietary recommendations. It is the aim of this article to provide vegan nutrition guidelines, based on current evidence, which can easily be communicated to vegan patients/clients, with the goal of ensuring adequate nutrient status in vegans.

One-carbon metabolism in children with marasmus and kwashiorkor

BACKGROUND

Kwashiorkor is a childhood syndrome of edematous malnutrition. Its precise nutritional precipitants remain uncertain despite nine decades of study. Remarkably, kwashiorkor's disturbances resemble the effects of experimental diets that are deficient in one-carbon nutrients. This similarity suggests that kwashiorkor may represent a nutritionally mediated syndrome of acute one-carbon metabolism dysfunction. Here we report findings from a cross-sectional exploration of serum one-carbon metabolites in Malawian children.

METHODS

Blood was collected from children aged 12-60 months before nutritional rehabilitation: kwashiorkor (N = 94), marasmic-kwashiorkor (N = 43) marasmus (N = 118), moderate acute malnutrition (N = 56) and controls (N = 46). Serum concentrations of 16 one-carbon metabolites were quantified using LC/MS techniques, and then compared across participant groups.

FINDINGS

Twelve of 16 measured one-carbon metabolites differed significantly between participant groups. Measured outputs of one-carbon metabolism, asymmetric dimethylarginine (ADMA) and cysteine, were lower in marasmic-kwashiorkor (median µmol/L (± SD): 0·549 (± 0·217) P = 0·00045 & 90 (± 40) P < 0·0001, respectively) and kwashiorkor (0·557 (± 0·195) P < 0·0001 & 115 (± 50) P < 0·0001), relative to marasmus (0·698 (± 0·212) & 153 (± 42)). ADMA and cysteine were well correlated with methionine in both kwashiorkor and marasmic-kwashiorkor.

INTERPRETATION

Kwashiorkor and marasmic-kwashiorkor were distinguished by evidence of one-carbon metabolism dysfunction. Correlative observations suggest that methionine deficiency drives this dysfunction, which is implicated in the syndrome's pathogenesis. The hypothesis that kwashiorkor can be prevented by fortifying low quality diets with methionine, along with nutrients that support efficient methionine use, such as choline, requires further investigation.

FUNDING

The Hickey Family Foundation, the American College of Gastroenterology, the NICHD, and the USDA/ARS.

Food Allergy and Intolerance: A Narrative Review on Nutritional Concerns

Adverse food reactions include immune-mediated food allergies and non-immune-mediated intolerances. However, this distinction and the involvement of different pathogenetic mechanisms are often confused. Furthermore, there is a discrepancy between the perceived vs. actual prevalence of immune-mediated food allergies and non-immune reactions to food that are extremely common. The risk of an inappropriate approach to their correct identification can lead to inappropriate diets with severe nutritional deficiencies. This narrative review provides an outline of the pathophysiologic and clinical features of immune and non-immune adverse reactions to food-along with general diagnostic and therapeutic strategies. Special emphasis is placed on specific nutritional concerns for each of these conditions from the combined point of view of gastroenterology and immunology, in an attempt to offer a useful tool to practicing physicians in discriminating these diverging disease entities and planning their correct management. We conclude that a correct diagnostic approach and dietary control of both immune- and non-immune-mediated food-induced diseases might minimize the nutritional gaps in these patients, thus helping to improve their quality of life and reduce the economic costs of their management.

Assessing patients' characteristics and treatment patterns among children with atopic dermatitis

BACKGROUND

Atopic dermatitis (AD) is the most common immune-mediated skin disease in childhood. Several treatment options for pediatric AD, both topical and systemic, are currently available. We carried out a single-center observational study with the aim of describing characteristics and treatment patterns in pediatric AD patients.

METHODS

The study included 867 patients aged ≤16 years (females 50.5%, mean patient's age 5.9 years, standard deviation ±3.6 years) with a previous doctor-confirmed diagnosis of AD who underwent balneotherapy at the Comano Thermal Spring Water Center (Comano, Trentino, Italy) from April to October 2014.

RESULTS

Among the patients included in the study, 41.2% had mild (SCORing Atopic Dermatitis, SCORAD 0-15), 43.6% moderate (SCORAD 16-40) and 15.2% severe AD (SCORAD > 40). A higher occurrence of reported food allergy was observed among children with more severe AD (p < 0.0001), while no association was found between AD severity and reported inhalant allergy or passive smoking (p = 0.15 and 0.92, respectively). Emollients (55.1%) and topical corticosteroids (TCS; 45.7%) were the main treatment options used in the previous month. The use of oral steroids and topical calcineurin inhibitors (TCI) was considerably less common (6.3 and 4.5%, respectively), while no patients were on systemic agents other than steroids. Among patients with severe AD, 9.8% had not used TCS, TCI or any systemic treatments. Moreover, 20.0% of the patients in the study population had followed elimination diets, although only 27.2% of them had a reported food allergy.

CONCLUSIONS

A significant difference in the prevalence of reported food allergy emerged across the different AD severity categories. Furthermore, although further data are necessary to confirm our findings, undertreatment in children with AD appeared to be very common, at least among those attending the Comano Thermal Spring Water Center. Moreover, many patients followed elimination diets in the absence of reported food allergy.

Difference between kwashiorkor and marasmus: Comparative meta-analysis of pathogenic characteristics and implications for treatment

Kwashiorkor and marasmus are two clinical syndromes observed in severe acute malnutrition. In this review, we highlighted the differences between these two syndromes by reviewing the data comparing kwashiorkor and marasmus in literature, combined with recent microbiological findings and meta-analysis. Depletion of antioxidants, vitamins and minerals were more severe in kwashiorkor than marasmus. This was consistent with the severe and uncontrolled oxidative stress associated with the depletion of gut anaerobes and the relative proliferation of aerotolerant gut pathogens. This relative proliferation and invasion of gut microbes belonging to the aerotolerant Proteobacteria phylum and pathogens suggested a specific microbial process critical in the pathogenesis of kwashiorkor. Liver mitochondrial and peroxisomal dysfunction could be secondary to toxic microbial compounds produced in the gut such as ethanol, lipopolysaccharides and endotoxins produced by Proteobacteria, particularly Klebsiella pneumoniae, and aflatoxin produced by Aspergillus species. The gut-liver axis alteration is characterized by oedema and a fatty and enlarged liver and was associated with a dramatic depletion of methionine and glutathione, an excessive level of free circulating iron and frequent lethal bacteraemia by enteric pathogens. This was consistent with the fact that antibiotics improved survival only in children with kwashiorkor but not marasmus. The specific pathogenic characteristics of kwashiorkor identified in this review open new avenues to develop more targeted and effective treatments for both marasmus and/or kwashiorkor. Urgent correction of plasma glutathione depletion, alongside supply of specific essential amino acids, particularly methionine and cysteine, early detection of pathogens and an antibiotic more efficient than amoxicillin in supressing gut Proteobacteria including K. pneumoniae, and probiotics to restore the human gut anaerobic mature microbiota could save many more children with kwashiorkor.

In Vitro Protein Digestibility and Fatty Acid Profile of Commercial Plant-Based Milk Alternatives

Plant-based milk alternatives (PBMA) are a new popular food trend among consumers in Europe and North America. The forecast shows that PBMA will double their value by 2023. The objective of this study was to analyze the nutritional value of commercial products in terms of their fatty acid profile and protein digestibility from commercial PBMA. Eight commercially available PBMA were selected for fatty acid analysis, performed with gas chromatography of methylated fatty acids (GC-FAME), and, from these, four commercial products (almond drink, hemp drink, oat drink, and soy drink) were selected for a short-term in vitro protein digestibility (IVPD) analysis. The fatty acid analysis results showed that most of the products predominantly contained oleic acid (C18:1 ω-9) and linoleic acid (C18:2 ω-6). Hemp drink contained the highest omega-6/omega-3 (ω6/ω3) ratio among all tested products (3.43). Oat drink and almond drink were the PBMA with the highest short-term protein digestibility, non-significantly different from cow’s milk, while soy drink showed the lowest value of protein digestibility. In conclusion, PBMA showed a significant variability depending on the plant source, both in terms of fatty acid composition and protein digestibility. These results provide more in-depth nutritional information, for future product development, and for consumer’s choice.

North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position Paper: Plant-based Milks

Parents and caretakers are increasingly feeding infants and young children plant-based "milk" (PBM) alternatives to cow milk (CM). The US Food and Drug Administration currently defines "milk" and related milk products by the product source and the inherent nutrients provided by bovine milk. Substitution of a milk that does not provide a similar nutritional profile to CM can be deleterious to a child's nutritional status, growth, and development. Milk's contribution to the protein intake of young children is especially important. For almond or rice milk, an 8 oz serving provides only about 2% or 8%, respectively, of the protein equivalent found in a serving of CM. Adverse effects from the misuse of certain plant-based beverages have been well-documented and include failure to gain weight, decreased stature, kwashiorkor, electrolyte disorders, kidney stones, and severe nutrient deficiencies including iron deficiency anemia, rickets, and scurvy. Such adverse nutritional outcomes are largely preventable. It is the position of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) Nutrition Committee, on behalf of the society, that only appropriate commercial infant formulas be used as alternatives to human milk in the first year of life. In young children beyond the first year of life requiring a dairy-free diet, commercial formula may be a preferable alternative to cow's milk, when such formula constitutes a substantial source of otherwise absent or reduced nutrients (eg, protein, calcium, vitamin D) in the child's restricted diet. Consumer education is required to clarify that PBMs do not represent an equivalent source of such nutrients. In this position paper, we provide specific recommendations for clinical care, labelling, and needed research relative to PBMs.

Veganism and paediatric food allergy: two increasingly prevalent dietary issues that are challenging when co-occurring

Vegan diets – defined as the exclusion of all foods of animal origin from the diet- are becoming popular. In recent years, the prevalence of food allergy has also increased, and disproportionately affects children. When vegan diets and food allergy co-occur, this combination can be challenging and pose risks of nutritional deficiencies, particularly during childhood. In this paper, we aim to summarise the major concerns regarding vegan diets and food allergy, review the literature on this topic, and provide some suggestions for healthcare providers, particularly dietitians and nutritionists, who work with food allergic, vegan patients and their family. When working with this patient population, a regular and complete medical nutrition history, including screening for any possible nutritional deficiencies, is warranted. Likewise, the routine tracking of serum markers (especially iodine, iron, zinc, calcium, Vitamins B12, D, B2, and A, selected n-3 fatty acids and protein, which are more abundant in animal vs. plant foods) and symptoms of co-morbid diseases, including asthma, is important, as comorbid diseases may increase energy and nutrient requirements. For infants and children, anthropometry ought to be tracked longitudinally at regular intervals to identify any deviations from the child’s previous growth pattern, and to accommodate any increased requirements for growth and development. Correct diagnoses, education and allergy management must be disseminated to the family in a clear and appropriate manner. Children with allergy may have increased nutritional needs due to comorbidity. This is complicated by coincident food allergy and vegan diet as both impose diet restrictions (limiting sources of important nutrients, need for dietary variety and/or increased consumption due to reduced bioavaliability).

Nutritional Issues in Food Allergy

Diet and nutrition play an important role in the development and management of food allergy. The diet of expectant mothers can have an effect on their offspring in terms of allergic outcomes. A host of confounding factors may influence this, with a maternal diet rich in fruits and vegetables, fish, vitamin D-rich foods associated with a lower risk of allergic disease in their children. More surprisingly, the consumption of milk and butter has also been shown to have a protective effect, especially in a farm environment. Similarly, the diet of the infant can also be important, not only in terms of breast feeding, but also the timing of the introduction of complementary foods, the diversity of the diet and the effect of individual foods on the development of allergy. One factor which has clearly been shown not to influence the development of food allergy is allergen avoidance by expectant mothers. In the infant diet, the manipulation of the gut microbiome to prevent the development of atopic disease is clearly an area which promises much, although studies have yet to provide a breakthrough in the prevention of atopic dermatitis. More concrete evidence of the value of diet in prevention has come from studies evaluating infant eating patterns which may protect gut health, through the consumption of large amounts of home-processed fruits and vegetables. The consumption of fish during the first year of life has also been shown to be protective. The importance of nutritional issues in children and adults who have a food allergy has become much more accepted in recent years. The primary allergenic foods in infancy and childhood, milk, egg, wheat and soy are also ones which are present in many foods and thus their avoidance can be problematic from a nutritional perspective. Thus, children with a food allergy can have their growth compromised through avoidance, especially pre-diagnosis, when foods may be excluded without any expert nutritional input. The management of a food allergy largely remains the exclusion of the offending food(s), but it is now clear that in doing so, children in particular can be at nutritional risk if insufficient attention is paid to the rest of the diet. Adults with food allergy are often thought not to need nutritional counselling; however, many will exclude a wide range of foods due to anxiety about trace exposure, or similar foods causing reactions. The avoidance of staple foods such as milk and wheat are common, but substitute foods very often do not have comparable nutritional profiles. Adults may also be more susceptible to on-line promotion of extreme nutritional regimes which can be extremely harmful. All food allergic individuals, whatever their age, should have a nutrition review to ensure they are consuming a healthy, balanced diet, and are not avoiding food groups unnecessarily.

Promoting and achieving excellence in the delivery of Integrated Allergy Care: the European Academy of Allergy & Clinical Immunology competencies for allied health professionals working in allergy

The multi-disciplinary team approach is an effective model for patient care. Allied health professionals (AHPs) are an important part of such teams, bringing specific knowledge and skills related to the target patient population. The AHPs most often involved in allergy care are nurses and dietitians. Nurses are often involved in the care of patients with all types of allergy and also with asthma, whilst allergy-specialist dietitians provide vital nutritional and dietary support for the diagnosis and management of food allergy. There are many other AHPs who have a role to play in allergy care, including physiotherapists, psychologists, pharmacists and speech therapists, and their involvement is likely to develop as allergy care becomes more rooted in the community. With the development of multi-professional teams comes the requirement for disease-specific knowledge and skill sets, with all allergy team members required to have baseline knowledge and competency of the condition being managed. Whilst some competencies for AHPs practising in other disease states have been published, none are available for allergic disease against which AHPs can be benchmarked. The European Academy of Allergy & Clinical Immunology (EAACI) recognised this need, and supported the establishment of a Task Force to develop allergy-focussed competencies for AHPs. The varied skills, expertise and professional background of the Task Force members enabled the creation of a set of allergy competencies relevant to all AHPs working in allergy. It is recognised that the training and allergy expertise of AHPs, and their role within the allergy setting, will vary considerably depending on the country. However, it is important for patient care, that all AHP involved in allergy services have access to training, of a sufficiently high enough level to be aspirational and enable the continued growth and development of a wide range of allergy services, given the increasing need. The EAACI competencies will provide an important benchmark for allergy knowledge and skills against which education and training can be designed and health care professionals can subsequently be measured. However, more importantly, the EAACI AHP allergy competencies will enable the development and reach of specialist allergy services, with allergy-specialist AHPs undertaking key roles, especially in the community care setting.

Cutaneous manifestations of nutritional deficiency

PURPOSE OF REVIEW

Childhood malnutrition is a major global health issue. It is often thought of as a developing world problem and therefore, underdiagnosed or misdiagnosed in developed countries. The delay in diagnosis and treatment can lead to increased morbidity and mortality. Cutaneous manifestations are often the initial presenting signs of nutritional deficiency. Early recognition is essential in timely initiation of the necessary interventions. This article will review pertinent cutaneous findings and systemic manifestations associated with common nutritional deficiencies.

RECENT FINDINGS

Malnutrition has historically been associated with poverty in developing countries. However, recent literatures suggest that the incidence of nutritional deficiencies continuous to rise among infants from developed countries, as a result of dietary restrictions because of perceived food allergies or intolerance. It is also an emerging finding in children with complicated medical problems.

SUMMARY

It is very important to raise awareness about cutaneous manifestations of nutritional deficiency as early and appropriate treatment results in excellent prognosis.

Increased Gut Redox and Depletion of Anaerobic and Methanogenic Prokaryotes in Severe Acute Malnutrition

Severe acute malnutrition (SAM) is associated with inadequate diet, low levels of plasma antioxidants and gut microbiota alterations. The link between gut redox and microbial alterations, however, remains unexplored. By sequencing the gut microbiomes of 79 children of varying nutritional status from three centers in Senegal and Niger, we found a dramatic depletion of obligate anaerobes in malnutrition. This was confirmed in an individual patient data meta-analysis including 107 cases and 77 controls from 5 different African and Asian countries. Specifically, several species of the Bacteroidaceae, Eubacteriaceae, Lachnospiraceae and Ruminococceae families were consistently depleted while Enterococcus faecalis, Escherichia coli and Staphylococcus aureus were consistently enriched. Further analyses on our samples revealed increased fecal redox potential, decreased total bacterial number and dramatic Methanobrevibacter smithii depletion. Indeed, M. smithii was detected in more than half of the controls but in none of the cases. No causality was demonstrated but, based on our results, we propose a unifying theory linking microbiota specificity, lacking anaerobes and archaea, to low antioxidant nutrients, and lower food conversion.