Obesity is a global epidemic. The rates of obesity in infants and children continue increasing, particularly in the more underserved sectors and most populous areas of the world. Nutrition in early life is a major determinant of childhood and adult obesity risk and sets the course for an individual's future metabolic health. Therefore, prevention is critical, and needs to start early, during gestation and the first 2 years after birth, a child's first 1000 days of life. Early life offers a unique opportunity for a child's parents and caregivers to provide such nutrition and to shape the food preferences and dietary habits that may last a lifetime. The paper discusses factors associated with overweight and obesity in childhood and later life, with a focus on those which can be variably modified in an infant's immediate environment, primarily via a child's caregivers. These include maternal weight and weight gain in pregnancy, mode of birth, perinatal and postnatal use of antibiotics, feeding of infant formula vs breastfeeding, feeding with a bottle, time of introduction of complementary foods and beverages, macronutrient composition of the infant diet (particularly excess protein, energy, and sugars), short sleep, excess of screen time and sedentary behaviors, and the lack of parental responsive feeding behaviors. Finally, we review some aspects of interventional approaches that can be taken. Obesity prevention will require continued social and environmental changes to support the goal of providing adequate nutrition and a level of energy intake in balance with each individual's needs and requirements.

The nutrition of infants in the first 1000 days of life, from conception through 2 years of age, has both immediate and long-term health consequences. Most of the global burden of disease, the increase in chronic non-communicable conditions, and its associated costs to individuals, communities, and society are related to poor nutrition and exacerbated by the coexistence of under- and overnutrition. New threats such as the COVID-19 pandemic are adversely affecting the energy intake and diet quality of infants and young children worldwide. The mechanisms explaining the relationships between early life nutrition and long-term health are increasingly better understood. These include nutrition-related metabolic, immune, neurocognitive, and epigenetic changes which program long-term health. We review the state of global infant and young child nutrition, its long-term health consequences, the mechanisms involved, and potential approaches to addressing these challenges. A holistic, whole of society approach, engaging stakeholders from all key disciplines and public and private sectors, and importantly, children's families and community, will be needed. Prioritizing investment in improving diets and lifestyles in the first 1000 days of life is society's greatest opportunity for progress.

BACKGROUND:Establishing energy requirements in infants and young children is important in developing age-appropriate diet recommendations but most published guidelines for energy requirements have 1 or more limitations related to the data underlying the calculations.OBJECTIVE:To develop a comprehensive set of daily energy requirements for infants and young children aged 0-24 mo meeting the ideals of worldwide applicability to all healthy children based on the use of the doubly labeled water (DLW) technique to measure total energy expenditure (TEE), the use of recent, international growth charts, and calculation of values across a wide range of body weight.METHODS:Daily estimated energy requirements (EERs) were calculated in 1-mo increments from 0 to 24 mo for boys, girls, and combined, using as inputs the following: 1) TEE measured using the DLW technique, 2) energy deposition estimates from the Institute of Medicine, and 3) body weight values from the 25th to 75th percentiles from the 2006 WHO growth charts. EERs were combined for age groups 0 to <6, 6-8, 9-11, and 12-24 mo by averaging EERs from individual months. The EER calculations were supported by a systematic literature review and a meta-regression of existing studies.RESULTS:Energy requirements naturally increase with age and are slightly higher in boys than in girls. The EERs derived in this study are similar to those in other recent international efforts.CONCLUSIONS:This updated set of EERs for infants and young children expand and improve upon the methodology used to establish previous published guidelines. These estimates have multiple potential uses including planning age-appropriate menus for the complementary feeding period, the development of foods that are more precisely targeted to the needs of infants and children at particular ages, and establishing macronutrient requirements within specific age groups based on a percentage of energy, such as dietary fat.

There are no published harmonized nutrient reference values for the complementary feeding period. The aim of the study was to develop proposals on adequate and safe intake ranges of micronutrients that can be applied to dietary guidance and menu planning. Dietary intake surveys from 6 populous countries were selected as pertinent to the study and reviewed for data on micronutrients. The most frequently underconsumed micronutrients were identified as iron, zinc, calcium, magnesium, phosphorus, potassium, and vitamins A, B6, B12, C, D, E, and folate. Key published reference values for these micronutrients were identified, compared, and reconciled. WHO/FAO values were generally identified as initial nutrient targets and reconciled with nutrient reference values from the Institute of Medicine and the European Food Standards Authority. A final set of harmonized reference nutrient intake ranges for the complementary feeding period is proposed.

Obesity is the largest and fastest growing epidemic of modern times, and transcends geographical, ethnic, and socioeconomic boundaries. The problem of childhood obesity risk is preceded to a great degree by infant growth phenomena. Gestation and the first 2 years of life significantly shape long-term growth, metabolic, immunologic, sensory, and behavioral patterns of individuals. This paper reviews the "modifiable factors" associated to childhood obesity, defined as feeding and related dietary, environmental, or behavioral practices that can be addressed by parents, and caregivers, in the immediate child's environment in their first years of life to promote long term health.

Vitamin B12 deficiency in patients with intestinal disease has been attributed to malabsorption, ileal resection, and small bowel bacterial overgrowth (SBBO). To the best of our knowledge, elevated serum vitamin B12 (VB12) levels in children with intestinal disease have not previously been reported. We report the incidence of elevated VB12 levels in this population. Methods: Laboratory and demographic data were collected for patients with short bowel syndrome (SBS) and intestinal dysmotility (ID) followed in the clinics at 2 institutions. Those who received tube feedings or a combination of parenteral nutrition (PN) and enteral nutrition (EN) for >3 months and whose VB12 levels were routinely monitored were included. Results: A total of 139 subjects were identified and medical records reviewed. 96 instances of elevated VB12 levels (>900 pg/ml) were identified in 46 (33%) of 139 subjects; 20 instances of low VB12 levels (<150 pg/ml) were identified in only 7(5%). Elevated VB12 levels ranged from 903->2000 pg/ml (limit of detection). Age range at initial high VB12 level: 3-286 months; mean: 60 months. Primary diagnoses: SBS (33), gastroschisis (4), pseudo-obstruction (5), IBD (3), microvillus inclusion disease/SB transplant (1). 33(72%) had partial or complete ileal resection; 31(67%) had resection of ileocecal valve (ICV). 32(33%) of elevated VB12 levels were found in 15 subjects while receiving no PN and no VB12 enterally beyond that in commercial formulas. Conclusions: Most children with SBS and ID receiving adequate nutrition have normal VB12 levels. Elevated VB12 levels were significantly more frequent (p < 0.05) than low levels, even in cases of ileal and ICV resection. These findings are contrary to the belief that VB12 deficiency is common in intestinal disease. Given that the source of VB12 (or its analogues) in humans is only dietary intake or bacterial synthesis in the gut lumen, we speculate that synthesis of VB12 from SBBO and absorption in the SB is responsible for the frequency of elevated VB12 levels in this population.

BACKGROUNDNonpathogenic live bacteria are consumed as food by many children, particularly in the form of yogurt. The tolerance and safety of long-term consumption of specific types and strains of probiotic bacteria are not well documented.OBJECTIVEThe goal was to evaluate tolerance to formulas containing 2 levels of probiotic supplementation and effects on growth, general clinical status, and intestinal health in free-living healthy infants.DESIGNThis was a prospective, double-blind, randomized, placebo-controlled study of healthy infants aged 3-24 mo. Infants were assigned to receive a standard milk-based formula containing 1 x 10(7) colony-forming units (CFU)/g each of Bifidobacterium lactis and Streptococcus thermophilus, formula containing 1 x 10(6) CFU/g each of B. lactis and S. thermophilus, or unsupplemented formula. Clinical outcomes included formula intake, gastrointestinal tolerance, anthropometric measures, daycare attendance, and history of illness.RESULTSOne hundred eighteen infants aged ( +/- SD) 7.0 +/- 2.9 mo at enrollment consumed formula for 210 +/- 127 d. There were no significant differences in age, sex, formula consumption, or length of study between groups. The supplemented formulas were well accepted and were associated with a lower frequency of reported colic or irritability (P < 0.001) and a lower frequency of antibiotic use (P < 0.001) than was the unsupplemented formula. There were no significant differences between groups in growth, health care attention seeking, daycare absenteeism, or other health variables.CONCLUSIONLong-term consumption of formulas supplemented with B. lactis and S. thermophilus was well tolerated and safe and resulted in adequate growth, reduced reporting of colic or irritability, and a lower frequency of antibiotic use.

Fructo-oligosaccharides (FOS) may have potential benefits, since they exhibit many soluble dietary fibre-like properties. Foods currently available for weaning infants are generally low in fibre content and lack these potential benefits. Data documenting tolerance of FOS in weaning foods are greatly lacking. Our present objective was to evaluate the tolerance and gastrointestinal effects of FOS-supplemented infant cereal used as a daily addition to the diet of healthy infants. Healthy infants were randomly assigned to receive either 0·75 g FOS per serving of cereal or placebo for 28 d. The primary outcome of interest was gastrointestinal tolerance, which was assessed by daily parental reporting of functional variables for 28 d, including stool patterns and signs and symptoms of gastrointestinal tolerance. Secondary outcomes were also measured including: cereal intake (g cereal and g FOS/d), stool pH, changes in anthropometric measurements and adverse events. The study population included a total of fifty-six infants, age range 16·2–46·2 weeks with a mean age of 32·5 (sd 8·9) weeks; twenty-nine infants were randomized to the control group (age 31·8 (sd 9·0) weeks) and twenty-seven to the FOS-supplemented group (34·7 (sd 8·9) weeks). Average daily total intake per infant and average intake per serving were similar in both groups. Average FOS consumption was 0·74 (sd 0·39) g/d and as high as 3·00 g/d. Stool consistency was less likely to be described as ‘hard’, and more likely to be described as ‘soft’ or ‘loose’, in the FOS v. control group. The mean number of stools per infant was 1·99 (sd 0·62) per d in the FOS-supplemented group compared with 1·58 (sd 0·66) in the control group (P=0·02). There were no differences between the groups in reporting for crying, spitting-up or colic. No differences were found for stool pH. FOS-supplements added to cereal were well tolerated in doses of up to 3·00 g/d. FOS consumption led to more regular and softer stools, without diarrhoea, as well as less-reported frequency of symptoms associated with constipation such as hard stools or skipped days without stool. The present study is one of few studies documenting tolerance to increased fibre intake in the form of FOS as part of a weaning food.

Probiotic agents have been shown to have significant clinical beneficial effects in the prevention and management of gastrointestinal and non-gastrointestinal conditions. These observations have led to work demonstrating that an important mechanism of these agents is their close interaction with the gut associated lymphoid tissue (GALT) and suggested immunomodulatory effects on systemic immune response. Studies on the possibility that prebiotic agents might directly or indirectly induce similar immunomodulation have only recently begun. The preliminary findings of several recent human clinical trials reviewed in this article indicate that prebiotics may indeed prove to be a clinically beneficial dietary supplement, in the context of novel nutritional strategies for the management of gastrointestinal and systemic conditions.

In the past century the beneficial roles of nonpathogenic bacteria in the intestinal lumen were described. In the past decade there has been a dramatic increase in scientific work supporting the concept that there are clinical benefits to ingesting specific nonpathogenic organisms (probiotics). The potential benefits of modifying the intestinal flora composition of certain high-risk groups, eg, premature infants, travelers, and children receiving antibiotics, are emerging in the literature. Studies documenting prophylactic and therapeutic benefits in acute viral gastroenteritis and in atopic disease point not only to the potential applications, but also to the fact that the mechanisms of action of these agents may be due to their interaction with the gut as an immunologic organ. The benefits documented thus far are of varying degree and are most likely dependent on the number of agents, the dose, the dosing patterns, and the characteristics of the host and its underlying luminal microbial environment. Consequently, the safety and specification of a particular probiotic agent and methods of delivery to a particular population for a particular purpose should be carefully documented before making broad recommendations. The cost-benefit assessment of adding probiotics to our diet for prophylactic or therapeutic purposes, as well as better regulation of these agents as commercial products, is also needed.

Numerous probiotic agents have been studied for the management of diarrheal disease. In particular? the prevention and management of acute viral diarrhea, the treatment of recurrent Clostridium difficile diarrhea, as well as the control of antibiotic-associated diarrhea seem to be areas of significant potential benefit. A few agents, including Lactobacillus GG, Lactobacillus reuteri, and Saccharomyces boulardii, seem to be promising agents for the amelioration of the course of acute diarrhea in children when used therapeutically. The use of other agents, particularly Bifidobacteria, supplementing the regular feed of infants may have an effect as prophylactic agents against acute diarrheal diseases. In general, in pediatric populations, the effect of probiotic agents appears to be most significant against viral (rotaviral) diarrhea, suggesting that an immunological mechanism is responsible for the beneficial effects. The numerous agents, doses, and populations used make generalization difficult. Nevertheless, it is clear probiotic agents are becoming an important part of the armamentarium against gastrointestinal problems in infants and children.

Journal of Pediatric Gastroenterology and NutritionVolume 29, Issue 4 p. 513-513 Abstracts: Annual Meeting of the North American Society for Pediatric Gastroenterology and Nutrition; Denver, October 21-24, 1999 GASTRO-INTESTINAL FUNCTION IN INFANTS CONSUMING A WEANING FOOD SUPPLEMENTED WITH OLIGOFRUCTOSE, A PREBIOTIC J Saavedra, J Saavedra Division of GI and Nutrition, Johns Hopkins University School of Medicine, Baltimore, MDSearch for more papers by this authorA. Tschernia, A. Tschernia Division of GI and Nutrition, Johns Hopkins University School of Medicine, Baltimore, MDSearch for more papers by this authorN Moore, N Moore Division of GI and Nutrition, Johns Hopkins University School of Medicine, Baltimore, MDSearch for more papers by this authorA Abi-Hanna, A Abi-Hanna Division of GI and Nutrition, Johns Hopkins University School of Medicine, Baltimore, MDSearch for more papers by this authorF. Coletta, F. Coletta Division of GI and Nutrition, Johns Hopkins University School of Medicine, Baltimore, MDSearch for more papers by this authorC Emenhiser, C Emenhiser Division of GI and Nutrition, Johns Hopkins University School of Medicine, Baltimore, MDSearch for more papers by this authorR Yolken, R Yolken Division of GI and Nutrition, Johns Hopkins University School of Medicine, Baltimore, MDSearch for more papers by this author J Saavedra, J Saavedra Division of GI and Nutrition, Johns Hopkins University School of Medicine, Baltimore, MDSearch for more papers by this authorA. Tschernia, A. Tschernia Division of GI and Nutrition, Johns Hopkins University School of Medicine, Baltimore, MDSearch for more papers by this authorN Moore, N Moore Division of GI and Nutrition, Johns Hopkins University School of Medicine, Baltimore, MDSearch for more papers by this authorA Abi-Hanna, A Abi-Hanna Division of GI and Nutrition, Johns Hopkins University School of Medicine, Baltimore, MDSearch for more papers by this authorF. Coletta, F. Coletta Division of GI and Nutrition, Johns Hopkins University School of Medicine, Baltimore, MDSearch for more papers by this authorC Emenhiser, C Emenhiser Division of GI and Nutrition, Johns Hopkins University School of Medicine, Baltimore, MDSearch for more papers by this authorR Yolken, R Yolken Division of GI and Nutrition, Johns Hopkins University School of Medicine, Baltimore, MDSearch for more papers by this author First published: 01 October 1999 https://doi.org/10.1002/j.1536-4801.1999.tb02483.xRead the full textAbout ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume29, Issue4October 1999Pages 513-513 RelatedInformation

Journal of Pediatric Gastroenterology and NutritionVolume 29, Issue 4 p. 520-520 Abstracts: Annual Meeting of the North American Society for Pediatric Gastroenterology and Nutrition; Denver, October 21-24, 1999 USE OF ENTERAL BECLOMETHASONE DIPROPIONATE SUSPENSION IN GASTRO-ENTERIC FISTULOUS INFLAMMATORY BOWEL DISEASE (IBD) IN A PEDIATRIC PATIENT WITH A MULTISYSTEM AUTOIMMUNE DISORDER A. Tschernia, A. Tschernia Division of Pediatric GI and Nutrition, Baltimore, MD Division of Pediatric Allergy and Immunology, Baltimore, MDSearch for more papers by this authorK Connor, K Connor Division of Pediatric GI and Nutrition, Baltimore, MD Division of Pediatric Allergy and Immunology, Baltimore, MDSearch for more papers by this authorL Mattis, L Mattis Division of Pediatric GI and Nutrition, Baltimore, MD Division of Pediatric Allergy and Immunology, Baltimore, MDSearch for more papers by this authorH Lederman, H Lederman Division of Pediatric GI and Nutrition, Baltimore, MD Johns Hopkins University School of Medicine, Baltimore, MDSearch for more papers by this authorJ Saavedra, J Saavedra Division of Pediatric GI and Nutrition, Baltimore, MD Division of Pediatric Allergy and Immunology, Baltimore, MDSearch for more papers by this author A. Tschernia, A. Tschernia Division of Pediatric GI and Nutrition, Baltimore, MD Division of Pediatric Allergy and Immunology, Baltimore, MDSearch for more papers by this authorK Connor, K Connor Division of Pediatric GI and Nutrition, Baltimore, MD Division of Pediatric Allergy and Immunology, Baltimore, MDSearch for more papers by this authorL Mattis, L Mattis Division of Pediatric GI and Nutrition, Baltimore, MD Division of Pediatric Allergy and Immunology, Baltimore, MDSearch for more papers by this authorH Lederman, H Lederman Division of Pediatric GI and Nutrition, Baltimore, MD Johns Hopkins University School of Medicine, Baltimore, MDSearch for more papers by this authorJ Saavedra, J Saavedra Division of Pediatric GI and Nutrition, Baltimore, MD Division of Pediatric Allergy and Immunology, Baltimore, MDSearch for more papers by this author First published: 01 October 1999 https://doi.org/10.1002/j.1536-4801.1999.tb02591.xRead the full textAbout ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume29, Issue4October 1999Pages 520-520 RelatedInformation

58 We conducted a double-blinded randomized controlled study to examine the effects of a pediatric weaning food supplemented with oligofructose (OF) on growth and health status in the pediatric population. Non breast-feeding infants attending daycare centers in Baltimore, MD and aged 4 months to 24 months were recruited and randomized to one of two groups; both received a standard infant cereal (Gerber, U.S.A.) for 6 months, with one group being supplemented with oligofructose (0.55 gram per 15 grams of cereal). Outcomes of this part of the study were general health status markers such as growth, frequency of reported febrile events, cold symptoms ("runny nose", "cough"), use of antibiotics and daycare absenteeism. The data was collected on a weekly basis by phone interview with the caregiver as well as by daycare observations. Standardized weight and length were obtained monthly. Subjects who consumed for less than 2 weeks were excluded from final statistical analysis. Results: 123 infants were enrolled and completed the study: 63 supplemented (S), 60 unsupplemented (US). Mean age at enrollment was 11.2±5.1 mo. and 12.3±5.6 mo. respectively. Average daily cereal intake was 32.6 gm in the supplemented group (representing 1.19 gm of OF) and 35.9 gm in the unsupplemented group. The children were followed for a total of 12,244 subject-days, 33.5 subject-years. No significant differences between the groups were noted with regards to age, gender, or length of study. (Table)Conclusions: Consumption of oligofructose-supplemented cereal resulted in adequate growth and was associated with reduction in febrile events, antibiotic use and day care absenteeism. Further studies are needed on the mechanisms by which prebiotics may yield these clinical benefits.TABLE

Journal of Pediatric Gastroenterology and NutritionVolume 27, Issue 4 p. 483-483 Annual Meeting of the North American Society for Pediatric Gastroenterology and Nutrition; Orlando, October 22–24, 1998 EFFECT OF LONG TERM CONSUMPTION OF INFANT FORMULAS WITH BIFIDOBACTERIA (B) AND S. THERMOPHILUS (ST) ON STOOL PATTERNS AND DIAPER RASH IN INFANTS J Saavedra, J Saavedra Johns Hopkins University, School of Medicine, Baltimore, MDSearch for more papers by this authorA Abi-Hanna, A Abi-Hanna Johns Hopkins University, School of Medicine, Baltimore, MDSearch for more papers by this authorN Moore, N Moore Johns Hopkins University, School of Medicine, Baltimore, MDSearch for more papers by this authorR Yolken, R Yolken Johns Hopkins University, School of Medicine, Baltimore, MDSearch for more papers by this author J Saavedra, J Saavedra Johns Hopkins University, School of Medicine, Baltimore, MDSearch for more papers by this authorA Abi-Hanna, A Abi-Hanna Johns Hopkins University, School of Medicine, Baltimore, MDSearch for more papers by this authorN Moore, N Moore Johns Hopkins University, School of Medicine, Baltimore, MDSearch for more papers by this authorR Yolken, R Yolken Johns Hopkins University, School of Medicine, Baltimore, MDSearch for more papers by this author First published: 01 October 1998 https://doi.org/10.1002/j.1536-4801.1998.tb01399.xRead the full textAbout ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume27, Issue4October 1998Pages 483-483 RelatedInformation

67 Management of distal esophageal narrowing secondary to a stricture or "tight" Nissen fundoplication (NF) can pose a challenging problem. In children with neurologic deficits, swallowing dysfunction and esophageal dysmotility can lead to pooling of secretions and aspiration. Esophageal resection, revision of fundoplication or cervical esophagostomy are surgical options of high relative risk. We present 2 cases where a temporizing alternative to surgical intervention was used. A 5 ½ year old boy with mental retardation and cerebral palsy (MR/CP) secondary to shaken baby syndrome required a NF and gastrostomy for oral-motor dysfunction and GE reflux. Radiographic evaluation showed a dilated distal esophagus with obstruction secondary to the NF. Repeated bougie dilatation did not resolve the obstruction. A 3 ½ year old boy with MR/CP due to perinatal asphyxia was evaluated following revision of a NF and development of a distal esophageal stricture. Both presented with excessive secretions and recurrent aspiration. A 16 French gastro-jejunal tube (Medical Innovations Corp., UT) was placed through the gastrostomy in the usual manner. Under endoscopic guidance, the jejunal limb was inserted retrograde into the distal esophagus and held in position with a silk string loop attached to its tip. The loop traversed the esophagus, exited the nostril, re-entered the gastrostomy adjacent to the GJ tube, and returned to the jejunal limb tip. The string loop allowed replacement of the jejunal limb in the esophagus without additional endoscopy. Drainage of secretions via the jejunal port was successful, and prevented further aspiration in both patients. Feedings were continued through the gastric port and were well tolerated. In one patient this allowed for adequate nutritional rehabilitation and surgical intervention after 6 months; in the other child the tube has been in place and functioning for 16 months. Conclusion: Use of a GJ tube with the jejunal limb placed in the esophagus for drainage offers a safe and efficient temporizing option, in cases of esophageal obstruction where a surgical intervention is not immediately indicated.