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Wegh CAM, Schoterman MHC, Vaughan EE, van der Zalm SCC, Smidt H, Belzer C, A Benninga M. Effect of prebiotic oligosaccharides on bowel habit and the gut microbiota in children with functional constipation (Inside study): study protocol for a randomised, placebo-controlled, multi-centre trial. Trials 2024; 25:238. [PMID: 38576033 PMCID: PMC10996211 DOI: 10.1186/s13063-024-08050-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 03/11/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Functional constipation (FC) in children is a common gastrointestinal disorder with a worldwide-pooled prevalence of 9.5%. Complaints include infrequent bowel movements, painful defecation due to hard and/or large stools, faecal incontinence, and abdominal pain. Prebiotic oligosaccharides have been shown to relieve constipation symptoms in young adults and elderly. However, sufficient evidence is lacking linking additional prebiotic intake to improve symptoms in children with FC. We hypothesise that prebiotic oligosaccharides are able to relieve symptoms of constipation in young children as well. METHODS In the present randomised, double-blind, placebo-controlled, multi-centre study, we will study the effects of two prebiotic oligosaccharides in comparison to placebo on constipation symptoms in children of 1-5 years (12 to 72 months) of age diagnosed with FC according to the Rome IV criteria for functional gastrointestinal disorders. The primary outcome measure will be change in stool consistency. Secondary outcomes include stool frequency and stool consistency in a number of cases (%). Tertiary outcomes include among others painful defecation, use of rescue medication, and quality of life. In addition, the impact on gut microbiome outcomes such as faecal microbiota composition and metabolites will be investigated. Participants start with a run-in period, after which they will receive supplements delivered in tins with scoops for 8 weeks, containing one of the two prebiotic oligosaccharides or placebo, followed by a 4-week wash-out period. DISCUSSION This randomised double-blind, placebo-controlled multi-centre study will investigate the effectiveness of prebiotic oligosaccharides in children aged 1-5 years with FC. TRIAL REGISTRATION ClinicalTrials.gov NCT04282551. Registered on 24 February 2020.
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Affiliation(s)
- Carrie A M Wegh
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Laboratory of Microbiology, Wageningen University & Research, Wageningen, The Netherlands.
| | | | | | - Sofie C C van der Zalm
- Laboratory of Microbiology, Wageningen University & Research, Wageningen, The Netherlands
| | - Hauke Smidt
- Laboratory of Microbiology, Wageningen University & Research, Wageningen, The Netherlands.
| | - Clara Belzer
- Laboratory of Microbiology, Wageningen University & Research, Wageningen, The Netherlands
| | - Marc A Benninga
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Baaleman DF, Wegh CAM, de Leeuw TJM, van Etten-Jamaludin FS, Vaughan EE, Schoterman MHC, Belzer C, Smidt H, Tabbers MM, Benninga MA, Koppen IJN. What are Normal Defecation Patterns in Healthy Children up to Four Years of Age? A Systematic Review and Meta-Analysis. J Pediatr 2023; 261:113559. [PMID: 37331467 DOI: 10.1016/j.jpeds.2023.113559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 06/08/2023] [Accepted: 06/12/2023] [Indexed: 06/20/2023]
Abstract
OBJECTIVE To summarize available data on defecation frequency and stool consistency of healthy children up to age 4 in order to estimate normal references values. STUDY DESIGN Systematic review including cross-sectional, observational, and interventional studies published in English, that reported on defecation frequency and/or stool consistency in healthy children 0-4 years old. RESULTS Seventy-five studies were included with 16 393 children and 40 033 measurements of defecation frequency and/or stool consistency. Based on visual inspection of defecation frequency data, a differentiation was made between two age categories: young infants (0-14 weeks old) and young children (15 weeks-4 years old). Young infants had a mean defecation frequency of 21.8 per week (95 % CI, 3.9-35.2) compared with 10.9 (CI, 5.7-16.7) in young children (P < .001). Among young infants, human milk-fed (HMF) infants had the highest mean defecation frequency per week (23.2 [CI, 8.8-38.1]), followed by formula-fed (FF) infants (13.7 [CI 5.4-23.9]), and mixed-fed (MF) infants (20.7 [CI, 7.0-30.2]). Hard stools were infrequently reported in young infants (1.5%) compared with young children (10.5%), and a reduction in the frequency of soft/watery stools was observed with higher age (27.0% in young infants compared with 6.2% in young children). HMF young infants had softer stools compared with FF young infants. CONCLUSIONS Young infants (0-14 weeks old) have softer and more frequent stools compared with young children (15 weeks-4 years old).
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Affiliation(s)
- Desiree F Baaleman
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Carrie A M Wegh
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Laboratory of Microbiology, Wageningen University & Research, Wageningen, The Netherlands
| | - Tessa J M de Leeuw
- Laboratory of Microbiology, Wageningen University & Research, Wageningen, The Netherlands
| | | | | | | | - Clara Belzer
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Hauke Smidt
- Laboratory of Microbiology, Wageningen University & Research, Wageningen, The Netherlands
| | - Merit M Tabbers
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marc A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ilan J N Koppen
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Baaleman DF, Wegh CAM, Hoogveld MTA, Benninga MA, Koppen IJN. Transanal Irrigation in Children: Treatment Success, Quality of Life, Adherence, Patient Experience, and Independence. J Pediatr Gastroenterol Nutr 2022; 75:166-172. [PMID: 35675698 PMCID: PMC9278699 DOI: 10.1097/mpg.0000000000003515] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 05/08/2022] [Indexed: 12/10/2022]
Abstract
OBJECTIVES To investigate the clinical effectiveness and patient experience of transanal irrigation (TAI) in children with constipation or fecal incontinence. METHODS Combined retrospective and cross-sectional study including pediatric patients who used a Navina TAI system. We retrospectively collected baseline characteristics and data on treatment success at 1- and 6-month follow-up (FU). Treatment success was defined as defecating at least 3 times per week and having less than 1 episode of fecal incontinence per week. We cross-sectionally assessed health-related quality of life (HRQoL), treatment adherence, treatment satisfaction (Treatment Satisfaction Questionnaire for Medication [TSQM]), illness perceptions, medication beliefs, and patient empowerment with validated questionnaires. RESULTS Thirty-four patients were included (median age at start TAI: 11 years old [range, 6-18]), 32 in the retrospective review, and 26 in the cross-sectional survey (median of 3 years after initiation). Most patients were diagnosed with functional constipation (n = 26; 76%) or a neurogenic bowel disorder (n = 6; 18%). Treatment success rates significantly improved at each FU compared with baseline (baseline: 4/25 [16%]; 1-month FU: 12/16 [75%], P = 0.008; 6-month FU: 11/18 [61%], P = 0.016; cross-sectional FU: 13/26 [50%], P = 0.008). HRQoL scores were high (PedsQL median, 73 [IQR, 54-85]). Adherence (defined as Medication Adherence Report Scale [MARS] ≥ 23) was low (36%), whereas TSQM effectiveness scores were high (median, 69 [IQR, 47-86]). The majority of children (61%) reported an increase in independence since TAI treatment. Patient empowerment (GYPES) levels were similar to those reported in children with other chronic conditions. CONCLUSIONS TAI with a Navina system is an effective bowel management system for children with intractable constipation or fecal incontinence.
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Affiliation(s)
- Desiree F. Baaleman
- From the Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- the Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - Carrie A. M. Wegh
- From the Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- the Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
- the Laboratory of Microbiology, Wageningen University & Research, Wageningen, The Netherlands
| | - Maxime T. A. Hoogveld
- From the Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marc A. Benninga
- From the Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Ilan J. N. Koppen
- From the Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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Wegh CAM, Baaleman DF, Tabbers MM, Smidt H, Benninga MA. Nonpharmacologic Treatment for Children with Functional Constipation: A Systematic Review and Meta-analysis. J Pediatr 2022; 240:136-149.e5. [PMID: 34536492 DOI: 10.1016/j.jpeds.2021.09.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 09/02/2021] [Accepted: 09/08/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the effectiveness and safety of nonpharmacologic interventions for the treatment of childhood functional constipation. STUDY DESIGN Randomized controlled trials (RCTs) evaluating nonpharmacologic treatments in children with functional constipation which reported at least 1 outcome of the core outcome set for children with functional constipation. RESULTS We included 52 RCTs with 4668 children, aged between 2 weeks and 18 years, of whom 47% were females. Studied interventions included gut microbiome-directed interventions, other dietary interventions, oral supplements, pelvic floor-directed interventions, electrical stimulation, dry cupping, and massage therapy. An overall high risk of bias was found across the majority of studies. Meta-analyses for treatment success and/or defecation frequency, including 20 RCTs, showed abdominal electrical stimulation (n = 3), Cassia Fistula emulsion (n = 2), and a cow's milk exclusion diet (n = 2 in a subpopulation with constipation as a possible manifestation of cow's milk allergy) may be effective. Evidence from RCTs not included in the meta-analyses, indicated that some prebiotic and fiber mixtures, Chinese herbal medicine (Xiao'er Biantong granules), and abdominal massage are promising therapies. In contrast, studies showed no benefit for the use of probiotics, synbiotics, an increase in water intake, dry cupping, or additional biofeedback or behavioral therapy. We found no RCTs on physical movement or acupuncture. CONCLUSIONS More well-designed high quality RCTs concerning nonpharmacologic treatments for children with functional constipation are needed before changes in current guidelines are indicated.
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Affiliation(s)
- Carrie A M Wegh
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Department of Pediatric Gastroenterology and Nutrition, Amsterdam, the Netherlands; Laboratory of Microbiology, Wageningen University & Research, Wageningen, the Netherlands.
| | - Desiree F Baaleman
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Department of Pediatric Gastroenterology and Nutrition, Amsterdam, the Netherlands
| | - Merit M Tabbers
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Department of Pediatric Gastroenterology and Nutrition, Amsterdam, the Netherlands
| | - Hauke Smidt
- Laboratory of Microbiology, Wageningen University & Research, Wageningen, the Netherlands
| | - Marc A Benninga
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Department of Pediatric Gastroenterology and Nutrition, Amsterdam, the Netherlands
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Wegh CAM, Hermes GDA, Schoterman MHC, Vaughan EE, Smidt H, Belzer C, Benninga MA. The Modified Bristol Stool Form Scale: A Reliable and Valid Tool to Score Stool Consistency in Dutch (Non)Toilet-trained Toddlers. J Pediatr Gastroenterol Nutr 2021; 73:210-216. [PMID: 34402810 DOI: 10.1097/mpg.0000000000003186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE The aim of the study was to assess whether the modified Bristol Stool Form Scale (m-BSFS) is reliable, valid and user-friendly to use by parents, grandparents, and day childcare employees to evaluate stool consistency in toilet and nontoilet-trained toddlers in the Netherlands. STUDY DESIGN Translation to Dutch and validity of the m-BSFS (scoring 32 general stool pictures) for 1 to 3 year old toddlers (n = 89) was evaluated by parents, grandparents, and day childcare employees. A subgroup of participants scored an additional 7 pictures of stools in a diaper to validate the m-BSFS for non-toilet-trained toddlers (n = 16). To determine inter-rater reliability, 2-way random effects single-rater intraclass correlation coefficient (ICC)consistency was used. Intra-rater reliability was measured by Cohen kappa (κ) by rating the same pictures in random order twice, with at least 1 week between the first and second scoring. RESULTS Inter- and intra-rater reliability of the m-BSFS were above recommended minimal standards of 0.61 for the 32 general stool pictures as well as for the 7 pictures of stools in a diaper. ICCconsistency for the general stool pictures of the first and second ratings were 0.71 (n = 89) and 0.79 (n = 77), respectively, with a κ of 0.71 (n = 77). ICCconsistency for the stools in diaper pictures of the first and second ratings were 0.93 (n = 16) and 0.93 (n = 15), respectively, with a κ of 0.77 (n = 15). CONCLUSIONS The m-BSFS is reliable, valid and user-friendly to use by Dutch-speaking parents, grandparents, and day childcare workers to evaluate stool consistency in both toilet- and nontoilet-trained toddlers in the Netherlands.
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Affiliation(s)
- Carrie A M Wegh
- Laboratory of Microbiology, Wageningen University & Research, Wageningen
- Department of Pediatric Gastroenterology and Nutrition, Emma's Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Gerben D A Hermes
- Laboratory of Microbiology, Wageningen University & Research, Wageningen
| | | | | | - Hauke Smidt
- Laboratory of Microbiology, Wageningen University & Research, Wageningen
| | - Clara Belzer
- Laboratory of Microbiology, Wageningen University & Research, Wageningen
| | - Marc A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma's Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
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Wegh CAM, Geerlings SY, Knol J, Roeselers G, Belzer C. Postbiotics and Their Potential Applications in Early Life Nutrition and Beyond. Int J Mol Sci 2019; 20:E4673. [PMID: 31547172 PMCID: PMC6801921 DOI: 10.3390/ijms20194673] [Citation(s) in RCA: 224] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 09/18/2019] [Accepted: 09/19/2019] [Indexed: 12/15/2022] Open
Abstract
Postbiotics are functional bioactive compounds, generated in a matrix during fermentation, which may be used to promote health. The term postbiotics can be regarded as an umbrella term for all synonyms and related terms of these microbial fermentation components. Therefore, postbiotics can include many different constituents including metabolites, short-chain fatty acids (SCFAs), microbial cell fractions, functional proteins, extracellular polysaccharides (EPS), cell lysates, teichoic acid, peptidoglycan-derived muropeptides and pili-type structures. Postbiotics is also a rather new term in the '-biotics' field. Where consensus exists for the definitions of pre- and probiotics, this is not yet the case for postbiotics. Here we propose a working definition and review currently known postbiotic compounds, their proposed mechanisms, clinical evidence and potential applications. Research to date indicates that postbiotics can have direct immunomodulatory and clinically relevant effects and evidence can be found for the use of postbiotics in healthy individuals to improve overall health and to relief symptoms in a range of diseases such as infant colic and in adults atopic dermatitis and different causes of diarrhea.
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Affiliation(s)
- Carrie A M Wegh
- Laboratory of Microbiology, Wageningen University and Research, 6708 WE Wageningen, The Netherlands.
| | - Sharon Y Geerlings
- Laboratory of Microbiology, Wageningen University and Research, 6708 WE Wageningen, The Netherlands.
| | - Jan Knol
- Laboratory of Microbiology, Wageningen University and Research, 6708 WE Wageningen, The Netherlands.
- Danone-Nutricia Research, 3584 CT Utrecht, The Netherlands.
| | - Guus Roeselers
- Danone-Nutricia Research, 3584 CT Utrecht, The Netherlands.
| | - Clara Belzer
- Laboratory of Microbiology, Wageningen University and Research, 6708 WE Wageningen, The Netherlands.
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Wegh CAM, Benninga MA, Tabbers MM. Effectiveness of Probiotics in Children With Functional Abdominal Pain Disorders and Functional Constipation: A Systematic Review. J Clin Gastroenterol 2018; 52 Suppl 1, Proceedings from the 9th Probiotics, Prebiotics and New Foods, Nutraceuticals and Botanicals for Nutrition & Human and Microbiota Health Meeting, held in Rome, Italy from September 10 to 12, 2017:S10-S26. [PMID: 29782469 DOI: 10.1097/mcg.0000000000001054] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The objective of this study was to investigate the effect of probiotics on functional abdominal pain disorders (FAPD) and functional constipation (FC). METHODS A systematic review was conducted, searching PubMed and Cochrane databases from inception to January 2018 for randomized controlled trials (RCTs) investigating the efficacy of probiotics in children aged 4 to 18 years with FAPD or children aged 0 to 18 years with FC. RESULTS A total of 657 citations were identified. Finally, 11 RCTs for FAPD and 6 RCTs for FC were included. Some evidence exists for Lactobacillus rhamnosus GG (n=3) in reducing frequency and intensity of abdominal pain in children with irritable bowel syndrome. There is no evidence to recommend L. reuteri DSM 17938 (n=5), a mix of Bifidobacterium infantis, Bifidobacterium breve and Bifidobacterium longum (n=1), Bifidobacterium lactis (n=1) or VSL#3 (n=1) for children with FAPD. No evidence exists to support the use of Lactobacillus casei rhamnosus LCR35 (n=1), B. lactis DN173 010 (n=1), B. longum (n=1), L. reuteri DSM 17938 (n=1), a mix of B. infantis, B. breve and B. longum (n=1), or Protexin mix (n=1) for children with FC. In general, studies had an unclear or high risk of bias. CONCLUSIONS Insufficient evidence exists for the use of probiotics in FAPD and FC, only L. rhamnosus GG seems to reduce frequency and intensity of abdominal pain but only in children with irritable bowel syndrome. A better understanding of differences in gut microbiota in health and disease might lead to better probiotic strategies to treat disease.
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Affiliation(s)
- Carrie A M Wegh
- Laboratory of Microbiology, Wageningen University and Research, Wageningen.,Department of Pediatric Gastroenterology and Nutrition, Emma's Children's Hospital Academic Medical Center, Amsterdam, The Netherlands
| | - Marc A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma's Children's Hospital Academic Medical Center, Amsterdam, The Netherlands
| | - Merit M Tabbers
- Department of Pediatric Gastroenterology and Nutrition, Emma's Children's Hospital Academic Medical Center, Amsterdam, The Netherlands
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Wegh CAM, Schoterman MHC, Vaughan EE, Belzer C, Benninga MA. The effect of fiber and prebiotics on children's gastrointestinal disorders and microbiome. Expert Rev Gastroenterol Hepatol 2017; 11:1031-1045. [PMID: 28737484 DOI: 10.1080/17474124.2017.1359539] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The bacteria received upon birth are the start of colonization of the approximately 1014 bacteria that are present in the mature human gastrointestinal tract, better known as the microbiota. The gut microbiota is implicated in gastrointestinal health, nutrient metabolism and benefits such as prevention of infection. Dietary fiber, including prebiotics, escape digestion in the small intestine and reach the colon intact, where they are partially or completely fermented by the gut microbiota. Areas covered: The possible interactions between dietary fiber, prebiotics and microbiota are discussed as well as how this relates to functional gastrointestinal disorders. During the first years of life the microbiota have not yet reached a stable state and is sensitive to disturbance by environmental factors. An imbalance in the microbiota early in life is found to be associated with several functional gastrointestinal disorders such as colic, functional abdominal pain, irritable bowel syndrome and constipation. Expert commentary: A better understanding of how gut microbial changes in early-life can impact gastrointestinal health might lead to new treatments or disease prevention. Nutritional strategies with fiber or prebiotics may support health due to modification of colonic microbiota composition and metabolic activity, for example by growth stimulation of Bifidobacterium and Lactobacillus.
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Affiliation(s)
- Carrie A M Wegh
- a Laboratory of Microbiology , Wageningen University and Research , Wageningen , The Netherlands.,b Department of Pediatric Gastroenterology and Nutrition , Emma's Children's Hospital Academic Medical Center , Amsterdam , The Netherlands
| | | | | | - Clara Belzer
- a Laboratory of Microbiology , Wageningen University and Research , Wageningen , The Netherlands
| | - Marc A Benninga
- b Department of Pediatric Gastroenterology and Nutrition , Emma's Children's Hospital Academic Medical Center , Amsterdam , The Netherlands
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