When should we use partially hydrolysed formulae for frequent gastrointestinal symptoms and allergy prevention?

Experts reviewed the literature to determine whether partially whey hydrolysed formulas (HF) offer benefits in the dietary management of frequent gastrointestinal symptoms and allergy prevention. Compared with standard cow's milk-based formulas, partially whey HF confer a limited protective effect against allergic disease in high-risk infants, particularly atopic dermatitis, but not respiratory allergies. No randomised clinical trials have been published on partially whey HF in infants with colicky symptoms. The group did not find sufficient evidence to support the use of partially whey HF in regurgitation, although recent data suggest that a thickened partially whey HF may be more effective. Partially whey HF, fortified with prebiotics and/or probiotics, with high levels of sn-2 palmitate in the fat blend or without palm oil, provide some benefit in functional constipation.

CONCLUSION

Overall, partially whey HF may offer a useful alternative to intact protein in the dietary management of common functional gastrointestinal symptoms.

Functional fermented milk products

Fermented foods have been used since prehistoric times. Their number, variety and geographic origin are considerable, and different substrates and agents including bacteria, yeasts and moulds have been used in their preparation. In the last few decades the scientific approach to the study of the participating microorganisms and the resulting products have provided a better understanding of their biological importance. Among the many health-related properties of fermented foods, effects on blood pressure have been described after casein hydrolysis by lactic acid bacteria. Peptides with antimicrobial activity, mainly against Gram-negative bacteria, and derived from casein have also been identified. This could explain, at least in part, the antidiarrheal effects of fermented products including those on traveler's diarrhea and against colonization by Helicobacter pylori. One of the best known advantages of fermented milk products is their capacity to improve lactose tolerance in hypolactasic subjects. With the growing prevalence of allergies and inflammatory bowel diseases, considerable interest has been focused on the effects of lactic acid bacteria in these conditions; there is evidence that these agents are associated with improvements in allergy; no such evidence exists for Crohn's disease or ulcerative colitis. A cholesterol-lowering capacity has also been described for some microorganisms. Not all the fermenting microorganisms have probiotic capacities as the latter are strain-specific.

Systematic review: are probiotics useful in controlling gastric colonization by Helicobacter pylori?

Helicobacter pylori is a highly prevalent pathogen considered as an aetiological factor for gastroduodenal ulcers, and a risk factor for gastric adenocarcinoma and lymphoma in humans. Most subjects colonized by this micro-organism are asymptomatic and remain untreated. In symptomatic patients, the antibiotic treatment has a high cost and is not 100% effective because of resistance to antibiotics and to moderate patient compliance. This review discusses the role of probiotics as alternative solutions to assist in the control of H. pylori colonization in at-risk populations. The evidence that some strains of Lactobacillus and Bifidobacterium are able to inhibit H. pylori growth through the release of bacteriocins or organic acids, and may also decrease its adhesion to epithelial cells, is reviewed. In addition, probiotics have a possible role in the stabilization of the gastric barrier function and the decrease of mucosal inflammation. Other aspects that are considered are the contribution of probiotics to the healing of the gastric mucosa linked to their antioxidant and anti-inflammatory properties. Clinical trials in colonized adults and children are reviewed, and suggest that probiotics do not eradicate H. pylori but maintain lower levels of this pathogen in the stomach; in combination with antibiotics, probiotics may increase eradication rate and/or decrease adverse effects. Papers suggesting similar effects on H. pylori by foodstuffs such as berry juice and some milk proteins are quoted. Regular intake of these and other dietary products might constitute a low-cost, large-scale alternative solution applicable for populations at-risk for H. pylori colonization.

Effect of acute cigarette smoking, alone or with alcohol, on gastric barrier function in healthy volunteers

BACKGROUND

Smoking is a risk factor for gastroduodenal ulcer and gastric adenocarcinoma. However, the pathophysiological mechanisms induced by acute cigarette smoking in the human gastric mucosa are poorly understood.

AIM

To evaluate the effect of acute cigarette smoking, alone or with alcohol, on the gastric permeability to sucrose, a specific marker of mucosal damage in the stomach.

SUBJECTS AND METHODS

Twenty healthy volunteers (8 smokers/12 non-smokers) were studied. Each fasted subject ingested 500 ml of a 20% sucrose solution and the amount of sucrose excreted in a 5-hour urine collection was measured by gas chromatography Four sucrose permeability tests were carried out: 1. basal, 2. while smoking 5 cigarettes, 3. after drinking 50 ml of a 40 degrees alcoholic beverage, 4. a combination of 2+3.

RESULTS

Sucrose excretion increased after alcohol ingestion (40.5 +/- 6.0 mg vs 143.1 +/- 28.9 mg, p = 0.002), but was not modified by acute cigarette smoking (34.4 +/- 5.9 mg). When alcohol and cigarettes were simultaneously consumed, the increase in alcohol-induced sucrose excretion was significantly reduced (73.1 +/- 16.6 mg, p = 0.03). Basal sucrose excretion was similar in smokers and non-smokers. However, in acute cigarette smoking, a decrease in sucrose excretion was observed in smokers (p = 0.02) but not in non-smokers.

CONCLUSIONS

These results indicate that acute cigarette smoking may tighten the gastric mucosa in habitual smokers and this is associated with a smaller increase of gastric permeability induced by alcohol.

Effect of Lactobacillus ingestion on the gastrointestinal mucosal barrier alterations induced by indometacin in humans

BACKGROUND

Chronic nonsteroidal anti-inflammatory drug (NSAID) ingestion strongly affects the gastrointestinal mucosa as a first stage before ulceration. Some Lactobacillus strains may stabilize the mucosal barrier by increasing mucin expression, reducing bacterial overgrowth, stimulating mucosal immunity and synthetizing antioxidant substances; these events are altered in NSAID-associated gastroenteropathy.

AIM

To determine whether ingestion of the probiotic Lactobacillus GG (LGG) protects the gastrointestinal mucosa against indometacin-induced alterations of permeability.

SUBJECTS AND METHODS

Four gastrointestinal permeability tests were carried out in random order in 16 healthy volunteers: (i) basal; (ii) after indometacin; (iii) after 5 days of living LGG ingestion before indometacin administration; (iv) after 5 days of heat-killed LGG ingestion before indometacin administration.

RESULTS

Indometacin significantly increased basal sucrose urinary excretion (29.6 mg [17.1-42.1] vs. 108.5 mg [68.2-148.7], P=0.0030) (means [95% CI]) and lactulose/mannitol urinary excretion (1.03% [0.73-1. 32] vs. 2.93% [1.96-3.90], P=0.00012). Heat-killed LGG did not modify the indometacin-induced increase of gastrointestinal permeability, while live bacteria significantly reduced the alteration of gastric (47.8 mg [31.1-64.6], P=0.012) but not intestinal permeability induced by NSAID.

CONCLUSIONS

Regular ingestion of LGG protects the integrity of the gastric mucosal barrier against indometacin, but has no effect at the intestinal level.

Altered maternal psychological profile as health risk factor in poor urban infants

To test the hypothesis that the increased health risk of children selected by a previously calculated and validated predictive model is associated with some maternal psychological characteristics, the universe of 107 mothers of children selected by this model was evaluated by means of Goldberg's General Health Questionnaire (GHQ-30), Raven (Ra) and Rorschach (Ro) tests; 37.4% were cases according to GHQ-30, 80.9% were < 50th percentile in Ra and 85% exhibited deviant responses in Ro tests. Children whose mother's IQ was < 50th percentile suffered more episodes of total morbidity (Tm) and of diarrhoea (p = 0.0364). Children whose mothers were normal in Ro had less Tm (p = 0.0364) and fewer respiratory symptoms (p = 0.0300) and tended to have less diarrhoea (p = 0.0690). In poor urban families in Santiago psychological maternal characteristics are associated with an increased health risk for the infants. Supportive programmes should consider both biological characteristics of the infants and maternal psychological needs.

Maternal neurotic symptoms and infants' risk of developing persistent diarrhoea

A previously calculated predictive model for health risk selects infants who suffer 4-5 times more morbidity than their unselected peers. Preliminary results suggested that this risk is related to maternal neurotic symptomatology. To evaluate this hypothesis, 52 consecutive mothers whose infants had a positive predictive score (Group 1) and 52 in whom this was negative (Group 2) were evaluated by means of Goldberg's General Health Questionnaire (GHQ-30). A total of 41.9% and 20.5% of the mothers in Groups 1 and 2, respectively, scored above 11 points in GHQ-30, established as the cut off point. It is concluded that among poor urban families in Santiago mothers of infants with high risk of persistent diarrhoea have increased frequency of detectable neurotic symptoms. New programs aimed at this type of infant should include psychological support for their mothers.

[Application of a predictive model for morbidity among middle socioeconomic class infants]

A predictive model which identifies infants who suffer 4 to 5 times more morbidity than their unselected peers was calculated in previous studies, in population of the low socio-economic stratum (SES) (Rev Med Chile 1992; 120: 342-8): Some families of the middle SES also seek care at the Primary Health Care System. Therefore, since our aim is to propose an instrument to be used at this level, the predictive model was applied in families of this stratum. Children identified by means of the model suffered as many episodes of diarrhea but not of other illnesses, as their peers of the low SES (4.8 vs 4.3 respectively). Families in whom the instrument was positive were fewer in the middle SES (6.8 vs 15.7%). Because during the study a campaign to prevent cholera was carried out in Santiago, and this may modify the predictor's performance, at the end of the follow up the model was validated again in families of the low-SES; results confirmed that children with a positive predictor suffered more diarrhea than those of the non-selected population (6.5 vs 3.4 episodes/children/year).

Effect of health education and primary care on diarrhoeal disease morbidity in children: evaluation of a predictive intervention model

Two groups of infants (intervention group n = 66, and control group n = 45) at risk of persistent diarrhoea (PD) as identified by a predictive model were followed for 12 months. Families were visited at home weekly; mothers in the intervention group received information about prevention and treatment of diarrhoea and were encouraged to seek help in the field station when their children became ill. These children suffered fewer days with any illness, diarrhoea, or respiratory episodes (p < 0.00001 each). Also, in this group, the incidence of PD decreased to the levels of nonselected population only in children whose mothers consulted for the episode of diarrhoea (2.8%). Results show that the intervention decreased the time children suffered diarrhoea and also respiratory and other illnesses. This suggests that the predictive model identified children with high risk but is not disease-specific. Risk appears to be related to maternal behaviours. The model may be useful in the community for detecting groups vulnerable to common paediatric illnesses, including diarrhoeal disease.

Effect of dietary nucleotide supplementation on diarrhoeal disease in infants

The effects of a nucleotide-supplemented formula on diarrhoeal disease was studied in 141 infants (group 1) who belonged to the low socioeconomic stratum; 148 controls (group 2) received the same formula but unsupplemented. Group 1 experienced less episodes of diarrhoea (109 versus 140), including less first episodes (74 versus 102; chi-square = 8.19, p < 0.004; odds ratio 2.01) and for a lesser number of days (807 versus 996 days); 45.0% and 31.1% of infants in groups 1 and 2, respectively, never developed episodes of diarrhoea. There were no differences in the clinical characteristics of the episodes or in the enteropathogens isolated from symptomatic or asymptomatic infants. The mechanisms through which nucleotides decrease the incidence of diarrhoeal disease in infants remain unclear.

Chronic iron intake and diarrhoeal disease in infants. A field study in a less-developed country

The effect of chronic iron intake on diarrhoeal disease was evaluated in children in a community of low socio-economic stratum in Santiago, Chile. Children were incorporated into each of two consecutive cohorts; each cohort was divided into two groups, one receiving iron-enriched milk (12 mg/l) (monthly average = 70 children) and the other a control milk (1 mg/l) (monthly average = 83 children), and each cohort was followed up for 6 months. The incidence of diarrhoea was higher among the iron-supplemented children (30.4 vs 25.5 episodes/100 children/month, P < 0.025). This was mainly due to results obtained in infants 3-8 months of age during the summer months. Supplemented infants had more bowel movements on day 1 (P < 0.03) and liquid or semi-liquid stools were passed for more than 15 days more frequently (P < 0.05). While no differences were detected in aetiology, Shigella-associated episodes were less common among iron-supplemented infants (P < 0.008). Asymptomatic shedding of enteropathogens significantly increased in infants 12-18 months of age receiving iron-supplemented milk. In areas with inadequate environmental sanitation, chronic iron supplementation may have negative effects on diarrhoeal morbidity, despite improving iron nutritional status.

[Application of a model for predicting morbidity in children from a low socioeconomic level]

An instrument to be used at a primary health care level was built on the basis of a predictive model for diarrhea obtained during a previous study. The instrument was applied to 720 mothers or caregivers of infants living in the Southeastern area of Santiago. 83 infants who fulfilled the requisites of the instrument were surveyed during July-August 1989 and compared to age, nutritional and socioeconomic status matched children not fulfilling the same requisites. Infants selected by the predictive instrument suffered 4 times more morbid episodes and respiratory infections and 5 times more diarrheal episodes than controls. Symptoms were present in them during 50% of the survey period as opposed to 14% in controls. Mothers of children at risk had inadequate behaviors in respect to health care of their children and did not follow many of the National Health programs available for their families. The predictive instrument tested may be useful to identify children at high risk of morbidity, creating the possibility for special interventions in them.

[Trial of milk with low-lactose contents in acute diarrhea]

Fifty infants with acute diarrhea (less than or equal to 5 days of duration) were refed with either a low-lactose formula (experimental group, N = 25) or whole powdered cow's milk (control group, N = 25). During a two-month follow up etiology, clinical course, changes of anthropometric parameters and tolerance to the milk products were evaluated. The etiology of diarrhoea, the mean duration of the episodes (3.6 +/- 1.9 and 3.9 +/- 1.9 days in the experimental and control group, respectively) and the clinical course were comparable in both groups. Nutritional parameters remained unchanged during and after the episode. In two children (8.3%) of the control group stools continued to be liquid, fecal pH was 5 and reducing substances were positive. They had to be refed with the low-lactose product to induce remission of the symptoms. Both products were well tolerated. These findings suggest that availability of low-lactose formulae may be advantageous in the clinical management of infants with acute diarrhea and evidence of lactose intolerance.