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Mezzomo TR, Dias MRMG, Santos T, Pereira RM. Dietary intake in individuals with phenylketonuria: an integrative review. NUTR HOSP 2024; 41:212-223. [PMID: 37705455 DOI: 10.20960/nh.04579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023] Open
Abstract
Introduction Introduction: the dietary intake of individuals with phenylketonuria (PKU) may vary widely according to different cultural eating habits, lifestyle, access to multidisciplinary team, and metabolic formulas available. Thus, knowing the dietary intake of this population makes it possible to tailor nutritional treatment strategies to impact their health. Objective: to analyze the evidence on the dietary intake of individuals with PKU. Methods: an integrative literature review was conducted on the dietary intake of individuals with PKU in the databases PUBMED, BIREME and Science Direct. Original articles that addressed the energy and macronutrient food intake of children, adolescents and/or adults with PKU were included in the study, without time restriction, in any language. A total of 384 articles were found and 27 articles were selected and analyzed. Results: evidence about the nutritional composition of their diet showed that individuals with PKU consume between 1160-2721 kcal of energy -7.2-17.4 % (32.4-76.9 g) of energy as protein, 45.9-69.2 % of energy as carbohydrates, 16.6-39 % of energy as lipids- and between 7.6 and 20 g of fiber. Conclusion: most individuals with PKU have low energy, protein and fiber intake, adequate lipid intake, and high carbohydrate intake. Metabolic control of the disease is still a challenge in all countries. Nutritional strategies to improve dietary nutritional composition and phenylalanine blood levels in individuals with PKU remain an urgent issue.
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Affiliation(s)
- Thais Regina Mezzomo
- Graduate Master's and Doctoral Program in Child and Adolescent Health. University Federal of Parana
| | | | | | - Rosana Marques Pereira
- Pos-Graduate Master's and Doctoral Program in Child and Adolescent Health. University Federal of Parana
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2
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Adams AD, Fiesco-Roa MÓ, Wong L, Jenkins GP, Malinowski J, Demarest OM, Rothberg PG, Hobert JA. Phenylalanine hydroxylase deficiency treatment and management: A systematic evidence review of the American College of Medical Genetics and Genomics (ACMG). Genet Med 2023; 25:100358. [PMID: 37470789 DOI: 10.1016/j.gim.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 12/08/2022] [Accepted: 12/08/2022] [Indexed: 07/21/2023] Open
Abstract
PURPOSE Elevated serum phenylalanine (Phe) levels due to biallelic pathogenic variants in phenylalanine hydroxylase (PAH) may cause neurodevelopmental disorders or birth defects from maternal phenylketonuria. New Phe reduction treatments have been approved in the last decade, but uncertainty on the optimal lifespan goal Phe levels for patients with PAH deficiency remains. METHODS We searched Medline and Embase for evidence of treatment concerning PAH deficiency up to September 28, 2021. Risk of bias was evaluated based on study design. Random-effects meta-analyses were performed to compare IQ, gestational outcomes, and offspring outcomes based on Phe ≤ 360 μmol/L vs > 360 μmol/L and reported as odds ratio and 95% CI. Remaining results were narratively synthesized. RESULTS A total of 350 studies were included. Risk of bias was moderate. Lower Phe was consistently associated with better outcomes. Achieving Phe ≤ 360 μmol/L before conception substantially lowered the risk of negative effect to offspring in pregnant individuals (odds ratio = 0.07, 95% CI = 0.04-0.14; P < .0001). Adverse events due to pharmacologic treatment were common, but medication reduced Phe levels, enabling dietary liberalization. CONCLUSIONS Reduction of Phe levels to ≤360 μmol/L through diet or medication represents effective interventions to treat PAH deficiency.
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Affiliation(s)
- April D Adams
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX; Division of Maternal-Fetal Medicine, Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
| | - Moisés Ó Fiesco-Roa
- Programa de Maestría y Doctorado en Ciencias Médicas, Universidad Nacional Autónoma de México (UNAM), Mexico City, Mexico; Laboratorio de Citogenética, Instituto Nacional de Pediatría, Mexico City, Mexico
| | | | | | | | | | - Paul G Rothberg
- Department of Pathology & Laboratory Medicine, University of Rochester Medical Center, Rochester, NY
| | - Judith A Hobert
- University of Utah School of Medicine, Salt Lake City, UT; ARUP Laboratories, Salt Lake City, UT
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Rondanelli M, Porta F, Gasparri C, Barrile GC, Cavioni A, Mansueto F, Mazzola G, Patelli Z, Peroni G, Pirola M, Razza C, Tartara A, Perna S. A food pyramid for adult patients with phenylketonuria and a systematic review on the current evidences regarding the optimal dietary treatment of adult patients with PKU. Clin Nutr 2023; 42:732-763. [PMID: 37001196 DOI: 10.1016/j.clnu.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 03/03/2023] [Accepted: 03/07/2023] [Indexed: 03/31/2023]
Abstract
Early dietary treatment is mind-saving in patients with phenylketonuria. A "diet-for-life" is advocated, aimed to prevent effects of chronic exposure to hyperphenylalaninemia. While adherence to diet is significant during childhood as patients are followed-up at specialized metabolic centers, during adolescence and adulthood percentage of patients discontinuing diet and/or lost at follow-up is still high. The process of passing skills and responsibilities from pediatric team to adult team is defined "transition". The goal of transition clinics is to set up specific multidisciplinary care pathways and guarantee continuity of care and compliance of patients to care. In 2017, "The complete European guidelines on phenylketonuria" were published. These guidelines, however, do not provide an easy way to illustrate to adult patients how to follow correct dietary approach. The purpose of this review is to evaluate current evidence on optimum dietary treatment of adults with phenylketonuria and to provide food pyramid for this population. The pyramid built shows that carbohydrates should be consumed every day (3 portions), together with fruits and vegetables (5 portions), extra virgin olive oil, and calcium water (almost 1 L/day); weekly portions can include 150 g potatoes walnuts and hazelnuts (20 g). At top of pyramid, there are two pennants. The green means that, based on individual metabolic phenotype and daily phenylalanine tolerance, patients need personalized supplementation (specific phenylalanine free amino acid mixtures, vitamins and omega 3 fatty acids); the one red indicates foods that are banned from diet (aspartame and protein foods exceeding individual dietary phenylalanine tolerance).
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Affiliation(s)
- Mariangela Rondanelli
- IRCCS Mondino Foundation, 27100 Pavia, Italy; Unit of Human and Clinical Nutrition, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy.
| | - Francesco Porta
- Department of Pediatrics, Città Della Salute e Della Scienza University Hospital, University of Torino, Piazza Polonia 94, 10126, Turin, Italy.
| | - Clara Gasparri
- Endocrinology and Nutrition Unit, Azienda di Servizi Alla Persona ''Istituto Santa Margherita'', University of Pavia, 27100 Pavia, Italy.
| | - Gaetan Claude Barrile
- Endocrinology and Nutrition Unit, Azienda di Servizi Alla Persona ''Istituto Santa Margherita'', University of Pavia, 27100 Pavia, Italy.
| | - Alessandro Cavioni
- Endocrinology and Nutrition Unit, Azienda di Servizi Alla Persona ''Istituto Santa Margherita'', University of Pavia, 27100 Pavia, Italy.
| | - Francesca Mansueto
- Endocrinology and Nutrition Unit, Azienda di Servizi Alla Persona ''Istituto Santa Margherita'', University of Pavia, 27100 Pavia, Italy.
| | - Giuseppe Mazzola
- Endocrinology and Nutrition Unit, Azienda di Servizi Alla Persona ''Istituto Santa Margherita'', University of Pavia, 27100 Pavia, Italy.
| | - Zaira Patelli
- Endocrinology and Nutrition Unit, Azienda di Servizi Alla Persona ''Istituto Santa Margherita'', University of Pavia, 27100 Pavia, Italy.
| | - Gabriella Peroni
- Endocrinology and Nutrition Unit, Azienda di Servizi Alla Persona ''Istituto Santa Margherita'', University of Pavia, 27100 Pavia, Italy.
| | - Martina Pirola
- Endocrinology and Nutrition Unit, Azienda di Servizi Alla Persona ''Istituto Santa Margherita'', University of Pavia, 27100 Pavia, Italy.
| | - Claudia Razza
- Endocrinology and Nutrition Unit, Azienda di Servizi Alla Persona ''Istituto Santa Margherita'', University of Pavia, 27100 Pavia, Italy.
| | - Alice Tartara
- Endocrinology and Nutrition Unit, Azienda di Servizi Alla Persona ''Istituto Santa Margherita'', University of Pavia, 27100 Pavia, Italy.
| | - Simone Perna
- Division of Human Nutrition, Department of Food, Environmental and Nutritional Sciences (DeFENS), Università Degli Studi di Milano, 20122 Milano, Italy.
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Gama MI, Pinto A, Daly A, Rocha JC, MacDonald A. The Impact of the Quality of Nutrition and Lifestyle in the Reproductive Years of Women with PKU on the Long-Term Health of Their Children. Nutrients 2022; 14:nu14051021. [PMID: 35267995 PMCID: PMC8912747 DOI: 10.3390/nu14051021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 02/24/2022] [Accepted: 02/24/2022] [Indexed: 11/29/2022] Open
Abstract
A woman’s nutritional status before and during pregnancy can affect the health of her progeny. Phenylketonuria (PKU), a rare disorder causing high blood and brain phenylalanine (Phe) concentrations, is associated with neurocognitive disability. Lifelong treatment is mainly dietetic with a Phe-restricted diet, supplemented with a low-Phe protein substitute. Treatment adherence commonly decreases in adolescence, with some adults ceasing dietary treatment. In maternal PKU, elevated blood Phe is harmful to the fetus so a strict Phe-restricted diet must be re-established preconception, and this is particularly difficult to achieve. A woman’s reproductive years introduces an opportunity to adopt healthier behaviours to prepare for successful pregnancies and positive health outcomes for both themselves and their children. Several factors can influence the health status of women with PKU. Political, socioeconomic, and individual food and lifestyle choices affect diet quality, metabolic control, and epigenetics, which then pre-condition the overall maternal health and long-term health of the child. Here, we reflect on a comprehensive approach to treatment and introduce practical recommendations to optimize the wellbeing of women with PKU and the resultant health of their children.
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Affiliation(s)
- Maria Inês Gama
- Nutrition & Metabolism, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Campo dos Mártires da Pátria 130, 1169-056 Lisboa, Portugal; (M.I.G.); (J.C.R.)
| | - Alex Pinto
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (A.P.); (A.D.)
| | - Anne Daly
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (A.P.); (A.D.)
| | - Júlio César Rocha
- Nutrition & Metabolism, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Campo dos Mártires da Pátria 130, 1169-056 Lisboa, Portugal; (M.I.G.); (J.C.R.)
- Reference Centre of Inherited Metabolic Diseases, Centro Hospitalar Universitário de Lisboa Central, 1169-045 Lisboa, Portugal
- CINTESIS—Center for Health Technology and Services Research, NOVA Medical School, Campo dos Mártires da Pátria 130, 1169-056 Lisboa, Portugal
| | - Anita MacDonald
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (A.P.); (A.D.)
- Correspondence:
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Burlina A, Biasucci G, Carbone MT, Cazzorla C, Paci S, Pochiero F, Spada M, Tummolo A, Zuvadelli J, Leuzzi V. Italian national consensus statement on management and pharmacological treatment of phenylketonuria. Orphanet J Rare Dis 2021; 16:476. [PMID: 34784942 PMCID: PMC8594187 DOI: 10.1186/s13023-021-02086-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 10/13/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Phenylketonuria (PKU) is a rare inherited metabolic disorder caused by defects in the phenylalanine-hydroxylase gene (PAH), the enzyme catalyzing the conversion of phenylalanine to tyrosine. PAH impairment causes phenylalanine accumulation in the blood and brain, with a broad spectrum of pathophysiological and neurological consequences for patients. Prevalence of disease varies, with peaks in some regions and countries, including Italy. A recent expert survey described the real-life of clinical practice for PKU in Italy, revealing inhomogeneities in disease management, particularly concerning approach to pharmacotherapy with sapropterin hydrochloride, analogous of the natural PAH co-factor, allowing disease control in a subset of patients. Therefore, the purpose of this paper is to continue the work initiated with the expert survey paper, to provide national guidances aiming to harmonize and optimize patient care at a national level. PARTICIPANTS The Consensus Group, convened by 10 Steering Committee members, consisted of a multidisciplinary crowd of 46 experts in the management of PKU in Italy. CONSENSUS PROCESS The Steering Committee met in a series of virtual meeting in order to discuss on clinical focuses to be developed and analyzed in guidance statements, on the basis of expert practice based evidence, large systematic literature review previously performed in the expert survey paper, and evidence based consensus published. Statements were re-discussed and refined during consensus conferences in the widest audience of experts, and finally submitted to the whole consensus group for a modified-Delphi voting. RESULTS Seventy three statements, divided in two main clinical areas, PKU management and Pharmacotherapy, achieved large consensus in a multidisciplinary group of expert in different aspects of disease. Importantly, these statements involve guidances for the use of sapropterin dihydrochloride, still not sufficiently implemented in Italy, and a set of good practice to approach the use of novel enzyme replacement treatment pegvaliase. CONCLUSIONS This evidence-based consensus provides a minimum set of guidances for disease management to be implemented in all PKU centers. Moreover, these guidances represent the first statement for sapropterin dihydrochloride use, implementation and standardization in Italy, and a guide for approaching pegvaliase treatment at a national level on a consistent basis.
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Affiliation(s)
- Alberto Burlina
- Division of Inherited Metabolic Diseases, Reference Center for Expanded Newborn Screening, DIDAS Servizi Di Diagnostica Integrata, University Hospital Padova, 35128, Padua, Italy
| | - Giacomo Biasucci
- Maternal and Child Health Department, Pediatrics and Neonatology Unit, Guglielmo da Saliceto Hospital, 29121, Piacenza, Italy.
| | - Maria Teresa Carbone
- Pediatric Division, Metabolic and Rare Diseases, Santobono Pausilipon Hospital, 80122, Naples, Italy
| | - Chiara Cazzorla
- Division of Inherited Metabolic Diseases, Reference Center for Expanded Newborn Screening, DIDAS Servizi Di Diagnostica Integrata, University Hospital Padova, 35128, Padua, Italy
| | - Sabrina Paci
- Paediatric Department, ASST Santi Paolo E Carlo, San Paolo Hospital, University of Milan, 20142, Milan, Italy
| | - Francesca Pochiero
- Metabolic and Muscular Unit, A. Meyer Children's Hospital, Florence, Italy
| | - Marco Spada
- Department of Pediatrics, Regina Margherita Children's Hospital, University of Torino, 10126, Turin, Italy
| | - Albina Tummolo
- Metabolic Diseases Department, Clinical Genetics and Diabetology, Giovanni XXIII Children's Hospital, 70126, Bari, Italy
| | - Juri Zuvadelli
- Paediatric Department, ASST Santi Paolo E Carlo, San Paolo Hospital, University of Milan, 20142, Milan, Italy
| | - Vincenzo Leuzzi
- Department of Human Neuroscience, Unit of Child Neurology and Psychiatry, University La Sapienza, 00185, Rome, Italy
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Large Neutral Amino Acid Therapy Increases Tyrosine Levels in Adult Patients with Phenylketonuria: A Long-Term Study. Nutrients 2019; 11:nu11102541. [PMID: 31640267 PMCID: PMC6835503 DOI: 10.3390/nu11102541] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/14/2019] [Accepted: 10/16/2019] [Indexed: 12/23/2022] Open
Abstract
The standard treatment for phenylketonuria (PKU) is a lifelong low-phenylalanine (Phe) diet, supplemented with Phe-free protein substitutes; however, adult patients often show poor adherence to therapy. Alternative treatment options include the use of large neutral amino acids (LNAA). The aim of this study was to determine the Phe, tyrosine (Tyr), and Phe/Tyr ratio in a cohort of sub-optimally controlled adult patients with classical PKU treated with a new LNAA formulation. Twelve patients received a Phe-restricted diet plus a slow-release LNAA product taken three times per day, at a dose of 1 g/kg body weight (mean 0.8 ± 0.24 g/kg/day), over a 12-month period. The product is in a microgranulated formulation, which incorporates all amino acids and uses sodium alginate as a hydrophilic carrier to prolong its release. This LNAA formulation provides up to 80% of the total protein requirement, with the rest of the protein supplied by natural food. Patients had fortnightly measurements of Phe and Tyr levels over a 12-month period after the introduction of LNAA. All patients completed the 12-month treatment period. Overall, adherence to the new LNAA tablets was very good compared with a previous amino acid mixture, for which taste was a major complaint by patients. Phe levels remained unchanged (p = 0.0522), and Tyr levels increased (p = 0.0195). Consequently, the Phe/Tyr ratio decreased significantly (p < 0.05) in the majority of patients treated. In conclusion, LNAA treatment increases Tyr levels in sub-optimally controlled adult PKU patients, while offering the potential to improve their adherence to treatment.
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Green B, Browne R, Firman S, Hill M, Rahman Y, Kaalund Hansen K, Adam S, Skeath R, Hallam P, Herlihy I, Jenkinson F, Nicol C, Adams S, Gaff L, Donald S, Dawson C, Robertson L, Fitzachary C, Chan H, Slabbert A, Dunlop C, Cozens A, Newby C, Bittle V, Hubbard G, Stratton R. Nutritional and Metabolic Characteristics of UK Adult Phenylketonuria Patients with Varying Dietary Adherence. Nutrients 2019; 11:nu11102459. [PMID: 31615158 PMCID: PMC6835765 DOI: 10.3390/nu11102459] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 09/30/2019] [Accepted: 10/11/2019] [Indexed: 01/20/2023] Open
Abstract
The nutritional and metabolic characteristics of adult phenylketonuria (PKU) patients in the UK with varying dietary adherence is unknown. In other countries, nutritional and metabolic abnormalities have been reported in nonadherent patients compared to adherent counterparts. A pooled analysis of primary baseline data from two UK multi-centre studies was therefore performed to establish whether this is true from a UK perspective. Adult PKU patients who had provided 3-day food records and amino acid blood samples were included and grouped according to dietary adherence (adherent; n = 16 vs. nonadherent; n = 14). Nonadherent patients consumed greater amounts of natural protein compared to adherent patients (61.6 ± 30.7 vs. 18.3 ± 7.7 g/day; q < 0.001). In contrast, the contribution of protein substitutes to total protein intake was lower in nonadherent compared to adherent patients (3.9 ± 9.2 g/day vs. 58.6 ± 10.2 g/day; q < 0.001). Intakes of iron, zinc, vitamin D3, magnesium, calcium, selenium, iodine, vitamin C, vitamin A and copper were significantly lower in nonadherent compared to adherent patients and were below UK Reference Nutrient Intakes. Similarly, intakes of thiamin, riboflavin, niacin, vitamin B6 and phosphorus were significantly lower in nonadherent compared to adherent patients but met the UK Reference Nutrient Intakes. Phenylalanine concentrations in nonadherent patients were significantly higher than adherent patients (861 ± 348 vs. 464 ± 196 µmol/L; q=0.040) and fell outside of European treatment target ranges. This study shows the nutritional and metabolic consequences of deviation from phenylalanine restriction and intake of PKU protein substitutes in nonadherent adult PKU patients. Collectively, these data further underlie the importance of life-long adherence to the PKU diet.
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Affiliation(s)
- Benjamin Green
- Medical Affairs, Nutricia Advanced Medical Nutrition, Wiltshire BA14 0XQ, UK.
| | - Robert Browne
- Medical Affairs, Nutricia Advanced Medical Nutrition, Wiltshire BA14 0XQ, UK.
| | - Sarah Firman
- Guy's and St Thomas' NHS Foundation Trust, London SE1 9RT, UK.
| | - Melanie Hill
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK.
| | - Yusof Rahman
- Guy's and St Thomas' NHS Foundation Trust, London SE1 9RT, UK.
| | - Kit Kaalund Hansen
- University College London Hospitals NHS Foundation Trust, London WC1N 3BG, UK.
| | - Sarah Adam
- Royal Hospital for Children, Glasgow, Glasgow G51 4TF, UK.
| | - Rachel Skeath
- Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK.
| | - Paula Hallam
- Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK.
| | - Ide Herlihy
- Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK.
| | - Fiona Jenkinson
- Royal Victoria Infirmary, Newcastle, Newcastle upon Tyne NE1 4LP, UK.
| | - Claire Nicol
- Royal Victoria Infirmary, Newcastle, Newcastle upon Tyne NE1 4LP, UK.
| | - Sandra Adams
- Royal Victoria Infirmary, Newcastle, Newcastle upon Tyne NE1 4LP, UK.
| | - Lisa Gaff
- Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK.
| | - Sarah Donald
- Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK.
| | | | | | | | - Heidi Chan
- Medical Affairs, Nutricia Advanced Medical Nutrition, Wiltshire BA14 0XQ, UK.
- Guy's and St Thomas' NHS Foundation Trust, London SE1 9RT, UK.
| | - Arlene Slabbert
- Guy's and St Thomas' NHS Foundation Trust, London SE1 9RT, UK.
| | - Carolyn Dunlop
- Royal Hospital for Sick Children, Edinburgh EH9 1LF, UK.
| | - Alison Cozens
- Royal Hospital for Sick Children, Edinburgh EH9 1LF, UK.
| | - Camille Newby
- Bristol University Hospitals NHS Foundation Trust, Bristol BS1 3NU, UK.
| | - Victoria Bittle
- Bristol University Hospitals NHS Foundation Trust, Bristol BS1 3NU, UK.
| | - Gary Hubbard
- Medical Affairs, Nutricia Advanced Medical Nutrition, Wiltshire BA14 0XQ, UK.
| | - Rebecca Stratton
- Medical Affairs, Nutricia Advanced Medical Nutrition, Wiltshire BA14 0XQ, UK.
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK.
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